Journal of Emergency Management

Table 6. Additional resources or information needed by advisors to better assist land managers/owners
with hurricane preparation (short and long term) and recovery (total respondents, n = 97; total number of
respondents who commented on short term (n = 79), recovery (n = 49), and long term (n = 60)) (continued)

Percentage Percentage Percentage Percentage Percentage

of respond- # of times of respond- # of times of respond- of respond- of respond-

Coded needs # of times ents who mentioned ents who mentioned ents who ents ents who

mentioned mentioned under ST mentioned under REC mentioned mentioned mentioned

this as a needs under ST needs under REC under LT under LT

need needs needs needs needs

  Economic aids or

emergency funds 6 6 2 3 0 0 4 7

general

  Incentives for 33000035
practices

Agency coordination 15 14 4 5 7 12 4 7

  Coordinated aid

efforts among 77232435

agencies

  Timely response of 4 4 0 0 4 8 0 0
disasters programs

  Updated records 4 4 2 3 1 2 1 2

Improved means to

communicate with 11 11 6 8 3 6 3 5

farmers

Establish, update,

and communicate 9 9 5 6 2 4 2 3

emergency plans

Record keeping and 7 7 4 5 2 4 1 2
paperwork

Farmer training 77561223

Improved 66111247
i­ nfrastructure

Other 88451235

Bold font indicates parent codes, and normal font indicates subcodes.

restored by 15 months after the hurricane.36 In our systems, hydroponics, and aquaculture. Electricity is
study, 71 percent of the participants considered power also essential for communication devices and com-
outages as having devastating effects on farms and puter systems involved in everyday business man-
ranches. Although many small farmers do not neces- agement. During power shortages, farmers commonly
sarily rely on electricity for production, electricity is relied on generators to continue operations; however,
generally used in a variety of essential tasks such as fuel was also scarce after the hurricane. A total of
the daily management of farm operations, irrigation 55 (31 percent) advisors considered both power and

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Vol. 19, No. 8

fuel shortages to be an obstacle for farm and ranch and ranchers during the recovery period. The absence
recovery (Table 4). Only 4 percent of the advisors of enough 4 × 4 vehicles was mentioned as an impor-
mentioned that power shortages were an impediment tant limitation to reach farmers in times of recovery.
for providing service during the hurricane recovery. Moreover, in our survey, more than 50 percent of the
Yet, power shortages posed an internal challenge for advisors consider that fallen trees had devastating
communication and coordination among agencies effects on agricultural lands across Puerto Rico and
given their dependence on telephones, the internet, USVI, eg, downed fences and blocked access. Our
computer equipment, and the failure of communica- study shows the urgency of incorporating a mecha-
tion towers connected to the power grid.37 nism to respond effectively to the removal of fallen
trees on farms and along transit routes to expedite
Limited telecommunication slowed the recovery the recovery process in agricultural areas.
process in the agricultural sector as agencies could
not effectively provide information on aid availability Preparedness and recovery
and application processes, which are usually accessed In investigating hurricane preparedness and
online. Farmers were asked to make in-person visits
to government offices to acquire information on avail- recovery strategies applied by farmers and ranchers,
able assistance and aid programs, despite transporta- our survey results suggested limited implementation
tion issues.37 From the advisors’ perspectives, lack- of long-term practices for hurricane resilience, though
ing phone communication to connect with farmers data indicated farmers implement some important
to check on their wellbeing and the status of their short-term preparedness and recovery strategies.
farm was a significant setback. More than half of the From the long-term strategies evaluated, all showed
advisors in our survey described that communication an importance-prevalence gap, meaning that even
issues such as downed phone lines or lack of internet though these strategies are considered important by
access had devastating impacts on agricultural lands advisors, the number of farmers or ranchers incorpo-
and operations. Likewise, approximately one-third rating them is limited.
of surveyed advisors consider that problems with
communication, internet, and downed phone lines Although many of the advisors indicated a high
impeded their ability to assist farmers and ranchers level of confidence in their ability to assist land man-
during the agricultural recovery process. agers on general topics related to hurricanes, the
results highlight a notable desire for more training,
Agriculture in rural mountains away from main workshops, and educational information on hurri-
roads likely suffered the most significant effects cane preparedness and recovery. A greater need was
associated with isolation due to a higher density expressed for educational resources for long-term
of landslides.38 Notably, the lack of road access sig- preparedness strategies. Agencies could modify previ-
nificantly hindered the livestock sector. For several ous resources to reflect the strategies needed to cope
weeks during the aftermath, distribution trucks could with the expected effects of more frequent and more
not access livestock farms to retrieve milk in a timely intense hurricanes foreseen for the region. As most
manner. As cows continued to be milked, millions of of the respondents acknowledge relying on train-
gallons of milk had to be discarded in many farms ing, workshops, and webinars, and resources from
around the island. Farms frequently relied on a gen- Cooperative Extension for hurricane information,
erator to operate, but the long-term dependency on these can be considered reliable venues to support
generators to run refrigeration tanks for milk storage advisors’ educational needs.
was not sustainable, especially with fuel shortages.39
Impassable roads hindered recovery in the agricul- Advisors in this study considered creating a hur-
tural sector in general. Advisors mentioned accessi- ricane preparedness plan to be the most important
bility, along with communication and transportation long-term strategy of those presented in the survey, but
issues as the principal challenge to assist farmers they perceived that fewer than 50 percent of farmers
and ranchers in the regions have developed or adopted

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150 Journal of Emergency Management
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one. Advisors also indicated that the lack of planning Other long-term practices that ranked high in
and coordination in government agencies created chal- their importance-prevalent gap are practices that can
lenges when assisting farmers and ranchers during be adopted with the technical or financial support
hurricane recovery. As there is an expected increase in from government agencies, ie, NRCS, including ero-
the frequency of intense hurricanes, hurricane prepar- sion control, contour planning, and crop diversifica-
edness that includes practices with long-term outcomes tion. Strategies that support better infrastructure,
for resiliency would be beneficial and should become a such as water storage resistant to winds, can also be
priority for all agrarian sectors in the US Caribbean. adopted with cost-share support from NRCS. However,
Anticipatory national-level planning that incorporates lack of information about conservation programs, con-
approaches for tackling the most devastating effects on flicting programs, and distrust in government, among
agriculture would likely reduce vulnerability and cost other variables, may hinder participation.42 Agencies
while decreasing recovery times. Also, it is important to should also evaluate the institutional barriers and
generate research on the effectiveness of agricultural policy inconsistencies that limit farmer and rancher
practices recommended for long-term hurricane resil- participation in agricultural conservation programs
ience applied in the Caribbean, as many of the current that can increase agricultural resilience to climate
standards come from experiences in the US mainland.12 events.42

Government agencies, through their advisors, The most prevalent long-term practice among
could more consistently connect with leaders from ranchers and farmers was investing in generators.
the different agricultural sectors, eg, poultry, banana, Although around 81 percent of the advisors indicated
and milk, in order to design tailored management that fuel shortage had a devastating or high impact
plans that incorporate lessons learned from the 2017 on the agricultural sector, stocking up on fuel for gen-
hurricanes. In addition to supporting sector-specific erators is a short-term preparedness strategy that
plans, government agencies would likely increase is prevalent in the region. Costs and access to fuel
effectiveness by considering coordination to help not constituted a significant challenge in the aftermath
only in the immediate response to hurricanes but also of the hurricanes. Both in Puerto Rico and USVI, the
long-term preparation for extreme climate events. For government is moving to supporting alternative ways
instance, government agencies can coordinate infor- of power operations in the agricultural sector, but
mation campaigns on program availability, develop many of these are costly. Suggested solutions include
and promote incentives that support long-term pre- highly distributed alternative power sources, local
paredness strategies, and streamline application pro- fuel distribution centers, plans aimed specifically
cesses to programs and aid. for agricultural customers, and renewable on farm
energy generation such as wind, solar, and biofuels.
Creating and securing a long-term seed bank was
another large prevalence-important gap. Respondents Applying for insurance and aid were recovery
also indicated that lack of seeds for crop recovery strategies prevalent among farmers and ranchers.
and for tree planting was a significant recovery chal- In Puerto Rico, the FIC is the Approved Insurance
lenge. The coffee and cocoa sectors, in particular, Provider (AIP) that sells and services federal crop
were affected by the lack of seeds to restore planta- insurance policies through a public–private part-
tions.40 After the hurricanes, the coffee sector rec- nership with USDA Risk Management Agency.
ommended importing seeds from outside of Puerto Nevertheless, coverage is limited to select crops and
Rico to increase available seeds from 2 to 7 million is not common on smaller farms, so many farmers
seeds, which could cut recovery times from 10 years were unable to access insurance benefits. Moreover,
to 2-3 years.41 Supported by Agricultural Extension there is no AIP for federal crop insurance in USVI.
Services, efforts are now underway to provide training Before the hurricanes, cocoa farming in Puerto Rico
and workshops in nursery management, and estab- was increasing, but the sector lost most income due to
lishing coffee nurseries and seed banks.40 hurricane damage and a lack of available insurance.

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Vol. 19, No. 8

Without income and very limited assistance for recov- research also shows that the resulting effects of such
ery, cocoa producers have struggled to resume their disasters on mental health are associated with long-
cocoa farming operations in Puerto Rico. With little to term problems in health, recovery, and the economy.46
no income, many employers were unable to pay wage To our knowledge, no post-hurricane assessments
workers, and many farm employees have been unable of first-responders’ psychological health have been
to resume work since the hurricanes.41 Financial conducted in Puerto Rico and USVI. Furthermore,
assistance for recovery was also mentioned by 17 the necessary training needed to cope with the post-
percent of the advisors as a challenge for recovery in hurricane psychological effects has yet to be evalu-
the aftermath of the hurricanes, largely associated ated. Training designed to deal with emotional stress
with the fact that so many farmers were in search of during hurricane response could be incorporated by
limited aid and with the challenges in providing the agricultural agencies that provide direct service to
requisite documentation and records. farmers.

Farm-level recovery was also greatly hindered Limitations
by the unavailability of supplies (seeds, fertilizer, Some limitations and challenges of this study
and feed), equipment, and machinery. These findings
echo previous post-hurricane observations in farms should be noted. First, some inconsistencies in
in Puerto Rico. Farmers expressed that the most sig- responses may have resulted from distributing both an
nificant obstacles toward recovering from hurricane online and paper version of the survey. However, due
María were related to farm-level recovery, followed by to the instability following these hurricanes, using only
government-related obstacles—eg, lack of planning online or only paper surveys was not feasible. Second,
and coordination, or lack of leadership—and lack of we requested that the survey be sent to staff who assist
utilities.43 In the coffee region of Puerto Rico, farm- land managers involved with hurricane preparedness
level management to control undesirable species, eg, and recovery. Given that the research team did not
vine cover and insects, was the most critical issue directly distribute the survey, we do not know precisely
for hurricane recovery.11 Farmers with resources to how many people received the survey, so we could not
eliminate vines, hire labor, or use herbicide proved calculate a response rate. The inability to calculate
to be more resilient than farmers without economic a response rate makes it difficult to determine if the
resources or community and support.11 survey was representative. Still, we believe the sample
size, ample participation across the various organiza-
Considering the challenges faced during the recov- tions, and the targeted outreach produced valuable
ery period, advisors expressed not having the skills results. Distribution through leadership was the most
to help farmers cope with the psychological effects appropriate mechanism available to us. Third, while
resulting from the hurricane devastation. In all, 16 agricultural advisors provide valuable insight into
percent of those who answered this question indi- land manager actions, the methodology is imperfect in
cated that they did not feel skilled enough to provide that respondents may not reach every land manager,
emotional or motivational support to farmers and and their perceptions may only reflect a portion of the
ranchers, and that they felt powerless to help them. challenges faced after the disaster. However, we believe
Also, their own personal and family needs were a sig- this study creates a baseline of information around
nificant challenge in the process of recovering from which to develop future studies and provides a rapid
the hurricane devastation. Emotional devastation or assessment after major hurricanes.
stress was prevalent among farmers in general.40 The
advisors, often the first to contact farmers, are faced CONCLUSIONS
with providing emotional support in times of crisis.
The psychological effects of natural disasters such The cost of extreme climate events is increasing
as hurricanes are known from experiences resulting dramatically, both in terms of the economic costs of
from hurricanes Mitch and Katrina.44,45 Previous individual events, and in terms of the economic, social,

Special Issue on Puerto Rico

152 Journal of Emergency Management
Vol. 19, No. 8

and ecological costs of compounding events, occurring in hurricane planning can be accomplished with
simultaneously or in rapid succession. Because of an increased level of organization and coordination
this, the cycle of disaster preparedness, response, and among agencies. Integrated efforts could include a
recovery is increasingly complex. The strain of larger revision of the aid application processes, as well as
and more frequent events has revealed gaps in the the development of sector-specific emergency and
way agencies collaborate to help citizens prepare for recovery guides. Every hurricane’s recovery period
and recover from disasters. Recovery resources do not illuminates opportunities to improve the response
reach all in equal measure. This was explicitly true efforts and to better attend to the needs of the agricul-
in the US Caribbean in recent years, as the region tural sector for future hurricanes. This study supports
suffered severe drought in 2014 to 2016, intense hur- the need for more coordinated efforts in the integra-
ricanes in 2017, and repeated earthquakes in 2020. tion and collection of data among emergency man-
The short time frame between disasters increases the agement and agricultural agencies to help expedite
vulnerability of agriculture and forestry operations hurricane response and mitigation. Our study also
to economic and functional losses. The imperative to reveals a gap in training and educational resources
learn from experience and improve communication on hurricane preparedness among agricultural advi-
and adoption of best practices is paramount to reduc- sors, particularly concerning long-term strategies. We
ing the risk of extreme climate events. emphasize the need for the development of training
for managing emotional distress of advisors, given
More specifically, climate projections indicate that while they support affected populations, they
that the Caribbean will experience more intense also suffer the effects of hurricanes themselves. With
hurricanes, increasing challenges to the islands’ agri- the certainty that hurricanes will continue to affect
cultural and economic development, and food secu- the Caribbean region, it is imperative to take proac-
rity. Agricultural advisors in this study perceived tive measures from the farm level to the agency level
the effects on farmlands in Puerto Rico and USVI to (1) improve efficiency and prevalence of prepared-
from the major hurricanes of 2017 to be significant ness and recovery efforts, (2) increase the resilience of
and devastating. Most significantly, the implementa- farm systems, road systems, and energy systems, and
tion of highly important practices for preparedness (3) support the psychological needs of those on the
before the arrival of the hurricanes was generally front lines and directly affected by hurricane events.
perceived as limited, except for the practices of stock
piling water or fuel. Despite stocking these resources, ACKNOWLEDGMENTS
shortages presented substantial challenges due to We are grateful for the generous participation of agency employ-
the length of the recovery period. Furthermore, the ees who helped distribute and participated in the survey. Special
recovery stage was perceived to be impeded by a lack thanks to those who pretested the survey: S. Brogan, L. Johnson, S.
of materials and equipment, transportation and com- Prieto-Pulido, E. Mas, R. Rodríguez, M. Argüelles, and J. Rosario.
munication issues, lack of planning, and ineffective Thanks to S. Aucoin, K. Jacobs, L. Villanueva, E. Holupchinski, B.
agency coordination. Finally, the incorporation of Maldonado, and A. Lugo for insightful comments to previous ver-
long-term preparedness practices important to face sions of the manuscript. T. Díaz and C. de Jesús assisted with survey
future hurricanes was perceived to be largely absent. translation. M. Andrade assisted with data entry. This manuscript
benefited greatly from the input of two anonymous reviewers. We
There is a pressing need to improve hurricane acknowledge the personnel of the Extension Service of the University
preparedness, response, and recovery to minimize of Puerto Rico at Mayagüez, who helped in different stages of the
effects on farmlands and to ensure the timely recovery project. All research at the USDA Forest Service International
of the agricultural sector in the Caribbean after hur- Institute of Tropical Forestry is done in collaboration with the
ricanes. Much of the improvements in these areas are University of Puerto Rico.
driven by a diverse set of agencies. As this study indi-
cates, planning, response, and recovery are impeded Nora L. Álvarez-Berríos, PhD, International Institute of Tropical
by a lack of agency coordination. Improvements Forestry, USDA Forest Service, Puerto Rico. ORCID: https://orcid.
org/0000-0001-7556-3156.

Sarah S. Wiener, MS (Forestry), USDA Forest Service, Ecosystem
Management Coordination, Washington, DC.

Special Issue on Puerto Rico

Journal of Emergency Management 153
Vol. 19, No. 8

Kathleen A. McGinley, PhD, International Institute of Tropical Forestry, 14. Bowers AW, Monroe MC, Adams DC: Climate change communi-
USDA Forest Service, Puerto Rico. cation insights from cooperative extension professionals in the US
Southern states: Finding common ground. Environ Commun. 2016;
Angela B. Lindsey, PhD, Center for Public Issues in Agriculture & 10(5): 656-670. DOI: 10.1080/17524032.2016.1176947.
Natural Resources, University of Florida, Gainesville, Florida. 15. Haigh T, Morton LW, Lemos MC, et al.: Agricultural advisors as
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William A. Gould, PhD, International Institute of Tropical Forestry, ity to communicate climate. Weather Clim Soc. 2015; 7(1): 83-93.
USDA Forest Service, Puerto Rico. DOI: 10.1175/wcas-d-14-00015.1.
16. United States Department of Agriculture: Census of agricul-
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JEM Individual response and recovery:
A learning experience from Hurricane María

Verónica Díaz-Pacheco, MS
Frederick González-Román

Clara Isaza, PhD
Thomas Richardson, MS

Robert Whalin, PhD
Mauricio Cabrera-Ríos, PhD

ABSTRACT highlighted the importance of developing decision
support tools for disasters.1 Some of the reasons why
Situations faced in the advent of powerful hurri- crisis managers need these include the inherent diffi-
canes can be stressful for individuals due to the uncer- culty in coordinating efforts,2,3 time sensitivity,4,5 and
tainty they bring along. The consequences of these lack of information during these events.6 Still, while
phenomena can leave individuals’ recovery in their efforts at higher levels become coordinated, individu-
own hands until order is re-established, and support als are the ones making decisions in their homes and
can reach out to them. This work aims to develop a tool communities to ensure their safety, survival, and
to guide individuals through their decision-making well-being. Observing this, in this study, we develop
during a hurricane disaster and recovery, using the a decision support tool for individuals’ well-being
experience of Hurricane María. The tool is a clas- during hurricanes—by using the experience during
sic inventory model adapted to monitor individual’s Hurricane Maria as a case study.
wellness through 48 hours after a hurricane arrival.
This article presents the three stages followed in the LITERATURE REVIEW
development in this work: the assessment of individu-
als’ sentiments toward Hurricane María via an online Hurricane María hit Puerto Rico on September 20,
questionnaire, the development of the mathematical 2017. The stressful circumstances during its aftermath
model, and the creation of a prototype in the form of were numerous: shortages of food and medicine, major
a mobile application. Each phase presents an impor- flooding and wreckage, infrastructure damage, lack of
tant contribution: a summary of first-hand knowledge electricity and water services for at least 3 months,7
obtained from the reactions of individuals who sur- lack or unpreparedness of shelters, landslides, and—in
vived Hurricane María, a novel modeling approach to the misfortunate cases—even loss of life. The poignant
the problem, and a convenient framework that synthe- memory of the event puts the death toll at approxi-
sizes both previous components. mately 3,0008 and quotes structural damages between
16 and 20 billion dollars.9 From María, we learned
Key words: individual emergency decision-making, that until help can reach out, individuals are often
disaster decision-making behavior, inventory model the ones making decisions in their homes to guaran-
applications, Hurricane María response and recovery tee their own safety and survival. This places crucial
importance on the quality of their decisions.
INTRODUCTION
Traditionally, decision-making is regarded as the
The increase in frequency and the magnitude process of selecting “rationally” between prospects a
of natural disasters over the last few years has

DOI:10.5055/jem.0548 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 157

choice that will maximize utility and minimize conse- of our knowledge, this is the first documented attempt to
quences.10 Some factors involved in decision-making approach this task. The purpose of the tool is to provide
include the current state of information and the a cognitive aid for individuals in moments of omnipres-
capacity to project outcomes for a choice.11 Evidently, ent uncertainty and stress. The advantage of using
the state of all these factors can fluctuate even more our prescriptive approach—as opposed to a descriptive
during disasters due to uncertainty and stress. Stress one—is that it is centered on detrimental events and
and worry are commonly mistaken for one another and key and manageable possible solutions, which renders it
although they are both anxiety related phenomena, independent of the people’s individual approaches. Since
they refer to different things. Stress is the “non-spe- the model uses real-time information during disasters, a
cific response of the body to a demand for change,” ie, mobile app prototype was developed to support its use.
a physiological reaction.12 Worry, on the other hand,
refers to a negative thought intrusion that occurs The following sections discuss the modeling
especially in conditions of ambiguity or possibility of approach’s three distinct phases of development:
negative outcomes.13 Since anxiety affects individuals (i) data gathering through an online questionnaire,
in different ways,14 we would expect worry to affect (ii) model creation, and (iii) mobile application devel-
decision-making in an individual manner too. opment. The results section synthesizes what was
learnt from each phase. Finally, conclusions and
Interestingly, another factor that affects decision- future work are discussed.
makers, especially in positions of power, is overconfi-
dence.2,11,15 Berner,16 for example, explores the idea STAGE 1: THE INDIVIDUAL EMERGENCY RESPONSE
and, in effect, finds overconfidence as a cause of
medical misdiagnosis. As it turns out, safety check- AND RECOVERY QUESTIONNAIRE
lists provide a simple yet effective solution for this
problem—a cognitive aid—especially for helping med- In the first stage, a preliminary study was carried
ical professionals avoid costly mistakes in operating out to understand decision-making and perceptions
rooms, where stress can be overwhelmingly present. during Hurricane María. The Individual Emergency
The use of this tool has been so successful that World Response and Recovery Questionnaire measured
Health Organization has even intended to introduce (i) worry levels about several categories, (ii) decisions
the use of Surgical Safety Checklists worldwide.17 made, and (iii) the amount of informal information
received by individuals at four different time points
While efforts directed to develop cognitive aids regarding María: during, 8 hours into, a day after,
exist for decision-makers at higher levels of emergency and a week after. Sociodemographical variables, like
management, close to none are directed at helping age, geographical region, etc., were also assessed.
individuals avoid suboptimal decision-making dur- From the survey results, we only present the set of
ing events. Furthermore, consultation of any resource data used to construct the model. Worry levels were
on decision-making for emergency management will measured on a five-point Likert scale and inquired
show that the objectives are safety and survival.2 On about 11 categories, as shown in Figure 1. After sur-
the other hand, there is a range of literature linking vey design, a sample (n = 52) was collected, and an
mental health18-20 and even well-being21-23 to natural exploratory data analysis was executed. It should be
disasters. Disaster recovery should, therefore, consider noted that the majority of respondents were in the
the well-being of individuals as an objective to conse- age group of 20-30 years old (79 percent). Also, for
quently achieve a healthier, more resilient response the purpose of analysis, time was grouped as follows:
and recovery as individuals, and as communities. worry during and worry after the event.

For this reason, in this work, we use the experience Results indicate that during María, individuals
during María to develop a tool—a mathematical model— were mostly worried about communications, friends
to enhance individuals’ decision-making for well-being and relatives, utilities, and plans for future. Two obser-
during the aftermath of a hurricane. To the best extent vations were consistent through time: this ordering by
categories and an overall decrease in each worry. The

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Figure 1.  Exploratory data analysis results: average an inventory to be maximized. Classical inventory
worry levels by category and time period. control models are used in manufacturing to main-
tain a level of inventory that minimizes production
worries that least changed through time were com- costs while meeting production demand.26 Using this
munications and utilities, which seemed reasonable framework for the problem at hand, a detrimental
since it took so long for these to be ­re-established after event, eg, losing a window in your place of shelter,
María. In contrast, the worries that most changed carries a detrimental effect—a reduction—on an
over time were for the house, for vehicles, and for individual’s wellness (well-being), while working on
pets. These observations were consistent through a restorative action, ie, a solution, would carry the
age groups. The worry levels of respondents seemed opposite effect. A wellness monitoring system during
to be composed significantly of their worry about hurricane emergencies was envisioned of this model
relatives and family. Interestingly, anxiety related that could query individuals periodically—every
to uncertainty about friends and relatives was a 2 hours, for instance—to register events that occurred
consistent finding in literature.24,25 Also consistent since the last time of query and reflect individuals’
with literature,25 an inverse relationship was found live wellness levels. Once events were reported, the
between worry and age group: younger individuals system would provide simple solutions, in this sense,
reported higher levels of worry than older ones. Also, in a prescriptive manner, to help mitigate detrimen-
age groups seemed to worry somewhat differently tal effects and restore the wellness level in the near
about some categories. For example, worry about stud- future.
ies was a large proportion of the total worry reported
by younger individuals, and older people reported Notation
having worried more than younger ones about friends The following mathematical notation was adopted
and relatives. Indeed, the exploratory data analysis
yielded interesting findings. It is our wish to address in order to discuss the wellness control model:
these associations with more significant statistical
power in a follow-up study, by increasing the sample Indices
size and through the development of a more robust
sampling strategy. Nonetheless, with this information i Time period i = 1, 2, 3, …, I
at hand, it was be possible to marshal an initial model.
j Detrimental event in time j = 1, 2, 3, …, ji
STAGE 2: MODEL DEVELOPMENT period i

Proposed framework k Detrimental event’s category k = 1, 2, 3, …, K
This work proposes that an individual’s level
l Detrimental event’s subcategory l = 1, 2, 3, …, lk
of wellness during a hurricane can be seen as
m Suggested solution to a m = 1, 2, 3, …, mkl
d­ etrimental event

n Solution in a particular time n = 1, 2, 3, …, ni
period i

Constants

I Number of time periods

ji Number of detrimental events in the ith time period
K Number of categories

lk Number of subcategories for the kth category
(event ID in category)

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mkl Number of suggested solutions for the klth event effect. Figure 2 illustrates how the mathematical
notation defined earlier comes together in the pro-
ni Number of restorations to take effect in the ith time posed model.
period
Events and solutions list
dkl Detrimental effect of the event in the kth category To develop a comprehensive listing of events
and the lth subcategory
and solutions for the system that could represent
dkl Detrimental effect in the ith period of the jth event scenarios after hurricane arrival, we surveyed indi-
ij in the kth category and the lth subcategory viduals who experienced Hurricane María first-hand.
Because the first period of impact can be the most
rklm Restorative effect associated to the mth solution in significant,24 scenario development was constrained
the kth category and the lth subcategory to the first 48-hours after hurricane arrival. The main
objective was to get the user to focus on critical deci-
nth restorative effect taking place in the ith time sions and feasible actions with a positive impact, so
the model took a prescriptive approach: it would only
rklm period associated to the mth solution in the kth suggest solutions that restored wellness. The number
in of solutions for each event was limited to a maximum
category and the lth subcategory of three (max{mkl} = 3). Furthermore, when pertinent,
only solutions that complied with standard safety and
ltklm Lead time for the restorative effect of the mth solu- health practices were adopted. For example, during
tion in the kth category and the lth subcategory the hurricane, an event like “Trapped in a flooded
building” would have only one solution: “Go to build-
Text variables ings highest level,” as is suggested by standard safety
practices.27
ekl Detrimental event, reported by user
ij The idea for the tool is to, eventually, enhance
already existing emergency management systems:
sklm Solution suggested by model areas of collective lowered wellness could indicate
ij areas that need attention. Hence, some of the solu-
tions provided by the system should be revised and
Numerical variables supervised by emergency managers, to ensure that
what the system suggests also aligns with their inter-
di Total detrimental effect a­ ssigned ji dklm ests for the collective.
to the ith time period ∑di = ij
Detrimental effects, restorative effects, and lead times
j In order to determine their detrimental effect on

ri Total restorative effect taking ni rklm wellness, every event on the list was
place in the ith time period ∑ri = in
i. classified in terms of whether it could
n happen during or after the event, following
the stratification developed in the “Stage 1:
Wi Wellness level in the ith time Wi =  Wi−1 − di +  ri the individual emergency response and
period recovery questionnaire” section, and

The way the system works is that individuals can ii. matched with a category of worry from
report any problem from a list of detrimental events, the questionnaire.
and this event will be classified at that moment using
a classification function:

f (eij ) = klm

Once reported by the user in time period i, the
classification function will identify the jth event
using its respective subindices (klm). This charac-
terization will help identify the event’s restorative
effect, and its respective lead time, that is, the time
(in hours) after which the restoration would take

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Figure 2.  Principal elements of a wellness model.

Afterwards, the magnitude of the detrimental effect. For example, the event Y “Lost electricity
effect on wellness of events, dkl, was defined as service” was associated with utilities and necessarily
occurred during the event. Using (1) and observing
X: (Level of worry___about___ ) × (1) Figure 1, dkl (Y) = 3.32×20 = 66, rounded to the near-
est integer. Solution #3 for Y “light candles” was pro-
Once each query in (1) is answered using a time visional; this solution’s restorative effect magnitude
point and a category, a value can be retrieved from was only 30. The net effect on wellness of reporting
Figure 1. The detrimental effect of an event was these instances would be a state of lowered wellness,
defined as the product of this value retrieved and a which is representative, to some extent, of the circum-
provisional arbitrary value of 20 ( = 20). This value stances of lacking electricity.
was introduced for scaling purposes. In this sense,
the impact an event would have on wellness would be In manufacturing settings, a lead time is the amount
subjective to what individuals reported to have wor- of time between order placement and the arrival of
ried about most. goods to customers. Using the proposed framework,
it follows that a solution’s lead time is the estimate of
The magnitude of the restorative effect, rklm, of the task’s completion time. This time was estimated for
the mth solution was determined as follows: if the every event on the list. When events occurred during
solution was provisional, ie, did not fix the problem the hurricane, but a solution could not be worked upon
entirely, the magnitude of the restorative effect was immediately, a lead time estimation looked as follows
lower than its detrimental effect. If the solution did
fix the problem entirely, the magnitude of the restora- Lead time (hours) = λ + estimate of solution (2)
tive effect was as large as the event’s detrimental ­completion time

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where λ = 8 hours, an approximation of the amount of contrasting objectives that individuals could very well
time of Hurricane María’s duration. adopt. Furthermore, for validation, several assumptions
were made regarding the simulation’s decision-making
STAGE 3: THE MOBILE APPLICATION PROTOTYPE strategy. First, only one solution for each detrimental
event would be selected. Second, in the case that solu-
During the third stage of this work, a mobile tions had the same lead time, the one with the highest
application was developed for the wellness inventory restorative effect was selected. Third, and last, if both
model. It was intended for this app to serve as the pri- restorative effects and lead times were the same, any
mary interface between individuals and the decision- of the solutions would be selected. Figure 5 shows the
making wellness monitoring system. The application, results of the validation strategy.
called iWILL (Individual Wellness Inventory Level
Log), was created using Microsoft’s Power Apps online DISCUSSION
platform. iWILL contains the decision support model
described previously, a revisable history of decisions Considerations in the first stage of the develop-
made by the user, and provides a source of continuous ment include the time lapse that has come to pass
real-time information during disasters along with vis- since the moment of occurrence of Hurricane María
ual aids. iWILL utilizes drop down menus with pre- and the survey: worry level can be subestimated
defined lists of events and solutions, as defined and due to the amount of time that has passed since the
discussed previously in this manuscript (Figure 3). event. Nonetheless, the data still hold value in the
The idea is to have a convenient interface that can comparative differences between worry categories.
warn users when their wellness state is low in order The authors agree that operationalizing something as
to avoid cognitive biases and bad decision-making, subjective as a level worry may be difficult, which is
which is very common during emergencies. It also why the model keeps its prescriptive nature.
has the capacity to work online and offline, as long as
there is battery in the hosting cell phone. Results from scenario development show the
model reflected the five individuals’ experience during
RESULTS: MODEL VERIFICATION AND VALIDATION Hurricane María sufficiently. Two important observa-
tions arose with this exercise: (i) the initial well-
To test the system, we collected the personal ness level must be assessed systematically on every
accounts—scenarios—of five individual’s experience instance and (ii) it is expected that after 48 hours, the
during Hurricane María. By verification, we mean individual wellness level differs from the initial level.
assessing the comprehensibility and sufficiency of Testing of the tool with more users should continue to
the events and solutions list to each case. The objec- refine the model and ensure its usability.
tive was to assess if the model could represent their
scenarios with reasonable fidelity. Figure 4 shows an Validation results show that adopting a decision-
instance of the resulting timed wellness profiles, as a making policy resulted in a different outcome; this
proof of concept. trend was observed consistently. The observed effect
was the following: adopting Policy I, shortest lead
To test the model’s sensibility, a protocol driven time, led to a higher wellness level than Policy II for
by random numbers was undertaken to create five some (short) time after the start of the simulation.
decision-making scenarios, ie, “random” profiles. The However, adopting Policy II, the highest restorative
protocol consisted of assigning each event in the list an effect, eventually led to a higher wellness level, for
ID (45 in total) and generating a set of 4-7 random inte- all runs. A limitation for validation is that it was
gers between 1 and 45 for each profile. For each profile, assumed that an individual would select a maximum
simulations were run adopting two different decision- of one solution for each detrimental event. The way
making strategies: pick the option with shortest lead the prototype is currently configured, and the reality,
time or pick the highest restorative effect, respectively. is that it may be possible for individuals to choose
These can be regarded as two strategies—policies—with more than one solution.

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Figure 3.  (Top) from left to right: app cover, user’s menu, and event history. (Bottom) from left to right: detri-
mental events entry screen, checklist screen with selected restorative actions, statistics screen with wellness
plot, and decision history.

The outcomes of the verification and validation CONCLUSION AND FUTURE WORK
stages evidence that the model provides at least
enough information to differentiate between individu- In this work, a tool to support decision-making dur-
als’ decision-making profiles and separate distinct ing hurricane disasters was developed using Hurricane
decision-making behaviors. María as a foundation. The tool’s implementation dur-
ing a real emergency could provide a valuable source

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Figure 4.  One of the personal profiles used for verification purposes.

Figure 5.  Random profiles for validation: runs 1 and 2.

of insight into decision-making behavior during emer- that the model logic can be further developed to cap-
gencies. Because the model has a prescriptive nature, ture the complexities of human decision-making and
it is our judgement that the tool as is could serve as a its effect on well-being. The authors are currently
cognitive aid to help individuals make better decisions undertaking these expansions to follow-up this pro-
by allowing them to work toward solutions that increase ject: a revised questionnaire and a target sample size
their well-being in situations where decision-making can will be achieved.
be, not only at it most uncertain, but at its most critical.
ACKNOWLEDGMENTS
It is undeniable that a larger sample, better This research was performed under an appointment to the US
representation across age and geographical groups, Department of Homeland Security (DHS) Science & Technology
and a revised questionnaire are important to arrive Directorate Office of University Programs Summer Research Team
to stronger conclusions in the future. We also believe Program for Minority Serving Institutions, administered by the

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164 Journal of Emergency Management
Vol. 19, No. 8

Oak Ridge Institute for Science and Education (ORISE) through an canada-45338080#:~:text=Officials%20in%20Puerto%20Rico%20
interagency agreement between the US Department of Energy (DOE) now,the%20previous%20estimate%20of%2064. Accessed September
and DHS. ORISE is managed by Oak Ridge Associated Universities 15, 2020.
(ORAU) under DOE contract number DE-SC0014664. All opinions 9. Estudios Técnicos Inc: Preliminary Estimate: Cost of Damages
expressed in this article are the author’s and do not necessarily by Hurricane María in Puerto Rico. Hato Rey, PR: Instituto de
reflect the policies and views of DHS, DOE, or ORAU/ORISE. Estadísticas de PR, 2017: 1.
10. Keeney RL, Raiffa H: Decisions with Multiple Objectives:
Also, we would like to express our most sincere gratitude to Preferences and Value Tradeoffs. New York, NY: Cambridge
Johany Negron, Justin Borrero, and Angelie Nieves for their assis- University Press, 1976.
tance, participation, and useful critique in this work. 11. Fischhoff B, Broomell SB: Judgment and decision mak-
ing. Ann Rev Psychol. 2020; 71: 331-355. DOI: 10.1146/annurev-
Verónica Díaz-Pacheco, MS, Department of Industrial Engineering, psych-010419-050747.
The Applied Optimization Group, University of Puerto Rico-Mayagüez, 12. Porcelli AJ, Delgado MR: Stress and decision making: Effects
Puerto Rico. ORCID: https://orcid.org/0000-0002-2582-4597. on valuation, learning, and risk-taking. Curr Opin Behav Sci. 2017.
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Notes

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JEM Provision of mental health services immediately following
a natural disaster: Experiences after Hurricane Maria
in Puerto Rico

Michelle E. Alto, PhD
Andel V. Nicasio, PhD
Regan Stewart, PhD
Tania D. Rodríguez-Sanfiorenzo, PhD
Gisela González-Elías, PhD
Rosaura Orengo-Aguayo, PhD

ABSTRACT On September 20, 2017, the Hurricane Maria
struck Puerto Rico as a high-end category four hurri-
Objective: The increased risk of mental health cane, making landfall only 2 weeks after the Hurricane
disorders in the months and years following a natu- Irma passed the island. Hurricane Maria caused the
ral disaster highlights the need for more immediate longest basic utility outage in US history, leaving many
preventive intervention. The objective of the current citizens of Puerto Rico without power, water, or com-
study was to learn from a real-time implementation munication for 3 months to over a year.1 Its cost to the
of a natural disaster response following the Hurricane infrastructure on the island reached $90 billion and
Maria in Puerto Rico to identify strategies for provid- an estimated 4,645 people lost their lives.1,2 A survey
ing mental health services immediately after a natural conducted with over 96,000 Puerto Rican youth high-
disaster. lighted widespread exposure to trauma,3 and 6 months
after the hurricane, residents continued to report sig-
Methods: Two focus groups were held with fac- nificant daily stressors related to the disaster.4
ulty (n = 6) and graduate students (n = 4) from a
graduate psychology program at the Universidad Puerto Ricans are not alone in this exposure to
Carlos Albizu, Centro Universitario Mayagüez. An natural disaster. Each year, approximately 175 mil-
additional key informant interview was conducted lion children and an even greater number of adults
with two faculty member participants. Data were ana- around the world are exposed to natural disasters.5
lyzed qualitatively using thematic analysis. This exposure increases risk for a range of mental
health problems, including post-traumatic stress dis-
Results: The delivery of mental health services order (PTSD), depression, traumatic grief, anxiety
was organized into three major themes: (1) finding a disorders, externalizing problems, and substance use
way to communicate, (2) targeting key access points disorders.6 Many Puerto Ricans experienced similar
for outreach and centralization of resources, and (3) mental health consequences following the Hurricane
providing triaged mental health care based on level Maria. For example, among adults in one small town
of need. on the east coast of the island, two-thirds of respond-
ents reported clinically significant symptom eleva-
Conclusions:  Findings are used to guide recom- tions for major depression, generalized anxiety, or
mendations for mental health response preparation in PTSD 6 months after the hurricane.4 Among youth
future natural disaster contexts.

Key words: hurricane, natural disaster, disaster
mental health response, psychological first aid

DOI:10.5055/jem.0634 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 167

across Puerto Rico, 7.2 percent (n = 6,900) reported following the Hurricane Maria. Graduate students
clinically significant symptoms of PTSD 5-9 months and their faculty supervisors from the Psychology
after the Hurricane Maria.3 Although these preva- Department at the Universidad Carlos Albizu,
lence rates highlight a significant need for mental Centro Universitario Mayagüez (UCA-Mayagüez)
health services about 6 months after a hurricane, lit- in Puerto Rico were part of the immediate response
tle is known about mental health needs and services effort following the hurricane. The purpose of this
in the days and weeks following natural disasters. study is to answer the following research question:
This window of time may present a critical opportu- how did UCA-Mayagüez faculty and graduate stu-
nity for immediate preventive intervention. dents support the mental health of Puerto Ricans
following the Hurricane Maria? The experiences of
Current guidelines for post-disaster mental these students and faculty can provide important
health interventions recommend three main phases information about how to access and serve popula-
of intervention: Phase 1: immediate aftermath (day tions in an immediate post-disaster setting with
of disaster to approximately 1 month); Phase 2: short- limited resources.
term recovery and rebuilding (approximately 1 month
to a year); and Phase 3: long-term recovery (approxi- METHODS
mately 1 year to several years).7 Focus in Phase 1 is
on restoring access to basic needs and using brief, Participants
present-focused interventions like psychological first A total of 10 participants took part in this study,
aid (PFA)8 to promote a sense of safety and security.9
The focus shifts to teaching evidence-based coping including six faculty members and four graduate
skills in Phase 2, using interventions like skills for students from UCA- Mayagüez. All graduate stu-
psychological recovery.10 In Phase 3, individuals with dents had a bachelor’s or master’s degree at the time
moderate to severe mental health needs are con- of participation and were enrolled in the Doctor of
nected with evidence-based psychotherapeutic inter- Psychology (PsyD) program. All faculty members had
ventions for trauma. a doctoral degree at the time of participation and were
part of the counseling, school, and clinical psychology
Following most natural disasters, it can take programs. Participants were all over the age of 18
providers months to organize, train, and identify indi- and were required to have provided mental health
viduals in need of mental health treatment, causing services immediately (1 day to 3 weeks) following
them to miss the opportunity for Phase 1 interven- the Hurricane Maria. All participants were female,
tion. However, some communities have successfully identified as Latina/Latinx, and all but one were born
coordinated an evidence-based Phase 1 response. For in Puerto Rico. All spoke Spanish and English, but
example, after a deadly mudslide and catastrophic focus groups and interviews were conducted in the
flooding in Sierra Leone in 2017, mental health nurses language of preference.
implemented PFA in combination with medical care
and service coordination.11 Within 1 week of the mud- Procedure
slide, nurses had delivered the intervention to over Participants were recruited with a flyer distrib-
1,000 affected individuals.11 This response is unique
because the mental health nurses were already well uted via email. Participants took part in one of two
trained in PFA and were therefore able to deploy focus groups (one for graduate students and one for
immediately to deliver services. Unfortunately, many faculty) in private rooms via a HIPAA-compliant
communities experience limited resources and unique video conferencing platform, with participants located
barriers that prevent them from being able to offer in Puerto Rico and focus group facilitators in South
such an immediate response. Carolina. Separate focus groups for students and
faculty were designed to minimize any potential
However, the community of Mayagüez had its power dynamics and capitalize on shared experiences
own unique approach to mental health services based on participants’ role and level of experience. An

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168 Journal of Emergency Management
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additional key informant interview was conducted codes within ATLAS.ti. Inter-rater discrepancies were
with two of the faculty participants via phone after the discussed and resolved.
focus groups took place. Researchers obtained ethical
approval for this study from the Medical University Next, second-level codes that synthesized first-
of South Carolina IRB, and all participants provided level codes were generated to establish a preliminary
informed consent prior to participation. thematic framework and work toward building an
explanation of how mental health services were deliv-
Focus groups were conducted in November 2019, ered immediately following the Hurricane Maria.12
and the key informant interview was conducted For example, the codes “radio,” “shelters,” “community
in February 2020. The second author conducted outreach,” “UCA- Mayagüez,” and “government” were
both focus groups in Spanish, and the third author captured by the theme “Access Points.” Transcripts
conducted the key informant interview in English. were then independently recoded by both coders to
A semistructured focus group guide was designed assess fit with the framework and identify confirma-
to answer the research question: “How did UCA- tory evidence for the model. Key informant interviews
Mayagüez faculty and graduate students support the were conducted as a purposeful sampling strategy
mental health of Puerto Ricans following Hurricane to confirm and disconfirm emerging themes14 and to
Maria?” Questions in both groups and the key inform- validate the data using a triangulation approach.15
ant interview covered topics in the areas of (1) Puerto Quotations associated with each code were organized
Ricans’ needs immediately following the Hurricane within ATLAS.ti, and those that best captured the
Maria, eg, What were people’s needs following the final themes were agreed upon between coders and
Hurricane Maria? What unique needs did you see included in the manuscript. The second author, whose
among children?, and (2) how participants met those first language is Spanish, back-translated the chosen
needs, eg, How did you access populations in need? quotations to ensure they were accurately translated.
What did mental health care look like? Focus groups
lasted 46 and 62 minutes. Focus groups did not last RESULTS
longer than 60 minutes to minimize the burden on
participants’ time and increase the likelihood that Findings suggest that the delivery of mental
participants would be available between their sched- health services immediately following the Hurricane
uled classes. The key informant interview lasted 32 Maria was organized into three major themes: (1)
minutes. Focus groups and the interview were audio finding a way to communicate, (2) targeting key access
recorded, deidentified, and transcribed verbatim, points for outreach and centralization of resources,
resulting in 56 pages of single-spaced transcription. and (3) providing triaged mental health care based
Transcripts were professionally translated before cod- on level of need. Each theme represents a key aspect
ing, and one of the coders, who is bilingual, reviewed of how mental health services were organized within
both the English and Spanish transcripts to assess this Phase 1 response.
the accuracy of the content.
Communication
Data analysis Because there was no electricity throughout the
Data were analyzed qualitatively using thematic
vast majority of the island after the Hurricane Maria,
analysis.12 ATLAS.ti 7 Mac software13 was used to communication became a significant need. Puerto
organize the data. First, two coders (the first and Ricans could not check on loved ones, spread informa-
second authors) independently completed the first- tion about resources, or organize response efforts over
level coding within ATLAS.ti to identify key ideas the phone, TV, or internet. As one faculty member
expressed by participants and develop a compre- explained:
hensive codebook. Both coders used this codebook
to independently analyze the data by marking their Not having communication I would say
was the most difficult thing, getting up

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and you don’t know what is going on half shelters, to provide services there, or to
an hour from your house in the rest of the the radio, or to the communities, to the
country. You don’t know anything at all. houses directly, right. So we had to make a
I think that was the most overwhelming switch in terms of what it is like to provide
part of not having communication. services in an office, right, with a schedule
agreement, and all the structure that we
This lack of communication was a significant typically have in traditional services.
stressor and contributed to an overwhelming sense
of uncertainty. People in need of mental health support could no
longer simply be referred to the university clinic.
As a result, the radio station became a critical Rather, students and faculty had to find a way to
resource for communication. Participants described identify those in need and reach them at these key
how people lined up at the radio station to send mes- access points.
sages to friends and family. Communication over the
radio also became an important way to spread infor- Because of its critical role in communication, the
mation about resources and available services. For radio became an important access point. Faculty and
the students and faculty at the UCA-Mayagüez, com- students at UCA-Mayagüez organized, so they could
munication via the radio station was the first step in assess and treat people waiting in line at the radio
organizing their response effort, as a faculty member station. One faculty member described how these ser-
described: vices were organized:

The only thing that was working was a We divided into time and days and then we
radio station, an AM radio station, and not only announced on the radio that we
this director went to the radio station and were available, but we attended to people
he let everyone know that UCA was all who came directly to the only station. [ … ]
right and that we were going to have a When the announcers or administrative
meeting with voluntary psychologists that staff identified that someone was in cri-
wanted to join and help us go to the com- sis or that they had some need to vent or
munities. something like that, they provided us with
a radio booth that obviously had at least
Given the damage of the hurricane, communication some confidentiality. [ … ] We also gave
could not have been possible without the radio station direct services there and also were able to
as a key resource. gather some referrals.

Access points The radio also became an access point for other basic
Once messages were communicated and ser- resources, like food, water, and medication. As a
result, it became a critical intervention setting.
vices coordinated, the next task in addressing men-
tal health became targeting access points for ser- Both pre-existing and emergency shelters, eg, sta-
vice delivery and centralization of resources. As one diums and schools, became another key access point.
faculty member described, mental health services As two faculty members explained:
changed to fit the post-disaster context:
We had already been active at the shelters
[The mental health] structure changed because of our other work, and the shelter
completely, because then [therapy] did at Mayagüez is very close to UCA [the
not necessarily take place in some spe- university]. So even though UCA wasn’t
cific centers, but it began by going to the open, we went there as soon as we heard

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on the radio that they were going to be being available for governments, entities,
meeting up.” and other organizations, connecting people
that didn’t know each other, and then they
Because of their pre-existing connections, these fac- continued and have created initiatives.
ulty members could bring graduate students with
them to the shelters to quickly increase their capacity. UCA-Mayagüez reopened within 3 weeks of the hurri-
cane, which also made it an important source of basic
Participants also organized to deliver services resources, eg, water and electricity, and emotional
directly in communities. Damage from the storm had support for graduate students. One faculty member
destroyed infrastructure and severely limited access described how she modified her course:
to several remote communities. One graduate student
recalled: At least one thing that I did in my course
was that at the beginning of each class
I remember that once I went with another when we met we talked for five minutes,
partner and we got stuck in the middle of ten minutes about how they had been, how
a hill and the car could not go up and we each one was. There was a space of relief
were doing it because there were people in around the circumstances. And once after
this community that did not have access. we talked a little about their experiences
They had no way to get down in order to and the things that others needed, they
receive these services. told each other, “Oh I have that, I can give
it to you,” etc.
Community outreach was important not only for
direct provision of services but also for distributing UCA-Mayagüez increased service capacity by con-
resources, spreading information, and identifying necting organizations and supporting its graduate
cases in need of referral. Sometimes, mental health student providers.
services were delivered right “in the field” in these
communities. One graduate student reflected on how Finally, the government was a major source of
people’s perceptions of mental health within the com- resources, placing service providers in shelters and
munities changed during this time. She explained offering access to important supplies, such as vehi-
how people were “eager to receive us” and “that vision cles that were equipped to reach remote communi-
that ‘this is for crazy people,’ that ‘I do not need it’ was ties. Government officials communicated with UCA-
totally opposite. Nobody refused, on the contrary they Mayagüez faculty and staff about the crises in the
were looking for us.” In this way, community outreach community. As one faculty member described:
was a way for UCA-Mayagüez graduate students and
faculty members to overcome both tangible and intan- When [government officials] had any situ-
gible barriers to mental health. ation in the communities that they had to
go handle, and there was something of a
UCA-Mayagüez itself became a central coordina- crisis, then they would alert us and some-
tion site for gathering resources and organizing ser- one from the psychological team would go
vices, as well as providing clinic-based mental health with them in the government cars and just
care for those with more acute needs. Importantly, go to the mountains, go to wherever was
UCA-Mayagüez served as a link between organiza- needed.
tions. One faculty member explained:
This collaboration with governmental officials allowed
We were able to provide help in another important information and resource sharing to better
way that didn’t have anything to do with serve the greater community.
psychology, right, like giving security,

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Triaged care is happening, ‘How long will we not have food?’ ‘When
Participants explained that their services fell into will the electricity return?’ That parental concern was
also very frequent.” The elderly also had unique needs,
three major domains: providing resources to meet the particularly with respect to medication and electricity
basic needs, offering empathy and support, and mak- to maintain their medical care. One graduate student
ing referrals for more intensive mental health treat- described how families did not know how to care for
ment. People often first requested information and the elderly under these circumstances:
supplies to attend to their basic needs. Psychological
services were either provided in tandem, or sequen- It was hard for me to see how many people
tially once basic needs were met. One graduate stu- were abandoned in the shelters, how their
dent walked through the process, saying: children brought the elderly to those shel-
ters for someone to take care of them, but
It all started by gathering [supplies] that we there came a time that shelter had to close
brought back. Then we took [the supplies] to and they could not find where to place
the places [ … ]. If it was identified that there those elderly.
were needs beyond the basics, then it was
referred or attended to immediately because Participants highlighted how addressing these basic
there were people there from the university, needs to establish stability and survive was often first
or a place was identified where the person and foremost on people’s minds.
could go, either in the same community if
there was one of us or another identified site The main emotional need that participants
that could assist them in terms of psychologi- observed was a sense of grief and loss. As one gradu-
cal needs and referrals for follow up. ate student aptly described: “Grieving is not only to
lose someone you love, but also economic or material
This process of assessment allowed graduate students things.” Participants observed that this sense of loss
and faculty members to tailor their services to meet was related to a lack of basic supplies, a sense of diso-
people’s most acute needs. rientation about how to move forward, uncertainty
about the future, death of loved ones, and a realiza-
Basic needs emerging among the population tion that things would never be the way they had
included food, water, clothing, shelter, electricity, been before the hurricane.
medication, and safety. Certain populations also had
unique needs. For example, children needed safe Although specific needs varied, students noted
spaces to play, particularly while their parents were that it was important to address every individual
addressing the family’s concrete needs. One of the with empathy and support. They explained how the
faculty members explained: fact they were all experiencing the same situation
brought everyone to the same level, helped with com-
At the shelters, […] our focus was the munication and fostered relationships. Specifically,
children. Because the families, they had a one graduate student highlighted the importance of
lot of family members that had to be doing suspending judgment about the extent of someone’s
the paperwork for FEMA. They had to do loss:
all sorts of stuff, so the children were left,
like, running around. We then went every And also not to minimize because there
day, we organized, we had some activities was someone in Puerto Rico who was more
[for the children]. affected than others, so I cannot assume
that since it was the same as where I live,
In addition, one graduate student described how par- that everyone saw it and experienced it
ents had the unique need “to explain to the child what from the same perspective.

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Participants emphasized the power of empathy and DISCUSSION
“humanity” as a simple intervention.
This qualitative study aimed to identify how
Finally, participants explained how a subset of graduate students and faculty members at UCA-
individuals required more intensive mental health Mayagüez in Puerto Rico organized and delivered
treatment. Several participants noted acute concerns mental health services immediately following the
related to suicidal ideation; one described a patient Hurricane Maria. Consistent with prior post-disas-
diagnosed with schizophrenia who could no longer ter research, communication emerged as a central
access his medication, and another explained that theme. Disaster communication interventions such as
her patient had a personality disorder that had not the disaster communication intervention framework
been detected until the hurricane. Those with more highlight the importance of providing information
significant mental health needs could be referred to about the event, safety, coping skills, resources, and
the UCA-Mayagüez university mental health clinic, social support to decrease disaster-related distress
which opened 3 weeks after the hurricane. and promote resilience.16 UCA-Mayagüez similarly
sought to provide information about these important
Some participants referred to this pattern of tri- topics, but encountered communication barriers due
aged care as PFA. Although faculty and students both to power outages and damaged infrastructure. As a
referenced a course on psychotherapy that included result, they capitalized on the local radio station to
an overview of PFA and noted that they received the provide this vital communication, as other communi-
PFA manual after the hurricane, there was discussion ties have also done in post-disaster contexts.17,18 This
among the graduate students about the formality of adaptation illustrates that one-way communication
their PFA training. One graduate student explained: can take place in contexts with limited resources
and highlights the radio as an important element of
I think we were not trained in Psychological future disaster preparedness plans.
First Aid [ … ]. After we started to provide
services, the manual was handed to us and The participants’ emphasis on access points
they explained to us what Psychological First aligns with research on cross-sector collaborations in
Aid was, but not formally. We were taught post-disaster contexts.19 As shown following the hur-
[ … ] we are going to ask about basic needs ricanes Katrina and Rita, cross-sector collaborations
first, we were given an idea about that, but can form post-disaster as an effort to compensate for
we were not taught Psychological First Aid. weakness in one sector and result in greater and more
effective public health response.20 For the faculty
However, another student stated: and graduate students at UCA-Mayagüez, previously
established collaborations, eg, shelters, radio, and
We were taking that class of Psychotherapy government, allowed for quicker response, while the
Techniques and we stopped everything circumstances of the hurricane also encouraged the
and were given Psychological First Aid formation of new collaborations facilitated by UCA-
[training] and also were given the manual. Mayagüez intended to strengthen future disaster
She trained us and from there we contin- responses. These findings emphasize the importance
ued to learn in the field. of identifying access points and creating cross-sector
networks as part of disaster response planning.
Despite this difference in opinion, graduate students
and faculty all described a pattern of triaged care that Finally, triaged care emerged as PFA-informed
consisted of identifying people’s most acute needs, response following the Hurricane Maria. The core
providing basic resources and support, and making actions of PFA, ie, contact and engagement, safety
referrals for those in need of more intensive mental and comfort, stabilization, information gathering,
health treatment. practical assistance, connection with social supports,
information on coping, and linkage with collaborative

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services,8 align with many of the themes identified Recommendations and conclusions
in this study. Official PFA training guidelines recom- These findings have important implications for
mend participation in a 6-hour online course and an
in-person training with a certified trainer. Although training and planning for future natural disaster
graduate students had been exposed to the tenets of response efforts, particularly as natural disasters
the model in their coursework and were able to refer- and global pandemics become increasingly common.
ence the manual, they were not formally trained in Graduate programs, schools, and government officials
PFA. However, their PFA-informed approach is con- should consider standardizing the formalized train-
sistent with Phase 1 natural disaster response guide- ing in PFA, along with training in traumatic stress,
lines7,21 and recommendations for the intervention post-disaster response, and self-care for responders.
during immediate and midterm post-mass trauma In addition, results suggest that post-disaster men-
phases, ie, sense of safety, calming, sense of self- and tal health response plans should address logistics,
community efficacy, connectedness, and hope,9 empha- like meeting spots for providers to organize and a
sizing the natural fit of UCA-Mayagüez’s response to way to communicate that does not require electricity.
the needs of the setting and the existing literature. Further, plans should capitalize on pre-existing cross-
Given the natural fit of PFA to the Phase 1 context, sector collaborations and incentivize the creation
these findings have important implications for PFA of new collaborations to facilitate resource sharing.
training prior to a natural disaster as they were Finally, plans should utilize graduate students as
observed in the successful response to the 2010 mud- important human resources and take advantage of
slides in Sierra Leone.11 the post-disaster context as a rich, in vivo training
environment for emerging mental health providers.
Limitations
It is important to consider these findings in the This study’s findings and implications offer impor-
tant opportunities for future research. Within the
context of several limitations. First, the sample size Puerto Rican context, assessing how this experience
of this study was limited by the number of students informed future disaster response plans within and
and faculty eligible and available to participate, due outside of Mayagüez could illustrate the generalizabil-
in part to the fact that Puerto Rico was struck by ity and sustainability of these findings. In addition, it
an earthquake in the middle of data collection. As a would be valuable to assess the relevance of these find-
result, data did not reach saturation. To counteract ings outside of Puerto Rico and in response to different
this limitation, we conducted additional key inform- kinds of natural disasters. This could be done by com-
ant interviews with two faculty members to further paring these results to Phase 1 responses in other con-
refine codes and triangulate the data.14,15 It is also texts or by implementing a Phase 1 response informed
important to note that findings also may not be by these findings in another setting. Finally, it would
generalizable to other forms of natural disaster or be important to assess the long-term impacts of this
other contexts. However, these results can still help response by following up with the individuals served
to inform future post-disaster Phase 1 interventions by UCA-Mayagüez and evaluating the impact of the
by highlighting the radio as a key communication subsequent steps taken by UCA-Mayagüez following
resource, identifying important access points, and this Phase 1 response on their well-being and mental
emphasizing the need for PFA training in prepara- health. These subsequent Phase 2 and Phase 3 services
tion for natural disasters. Finally, transcripts were are described elsewhere by Orengo-Aguayo et al.21,22
translated to English prior to coding because the first
author is not fluent in Spanish, which may have intro- The Phase 1 response period is critical for stabi-
duced some error. However, translation was done by lization and prevention of mental health disorders
a professional translator and checked by a bilingual following a natural disaster.7 By quickly identifying a
research team member to ensure accuracy. means of communication, targeting key access points,
and providing triaged mental health care, mental
health providers can more effectively and immediately

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serve survivors. In doing so, mental health providers 6. Bonanno GA, Brewin CR, Kaniasty K, et al.: Weighing the costs
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7. La Greca AM, Silverman WK: Treatment and prevention of post-
ACKNOWLEDGMENTS traumatic stress reactions in children and adolescents exposed to
We would like to thank the faculty and graduate students at the disasters and terrorism: What is the evidence? Child Dev Perspect.
Universidad Carlos Albizu, Centro Universitario Mayagüez, Puerto 2009; 3(1): 4-10.
Rico (UCA) for the incredible service they provided to their com- 8. Brymer MJ, Jacobs A, Layne CM, et al.: Psychological First Aid:
munities after the Hurricane Maria and without whom this work Field Operations Guide. 2nd ed. National Child Traumatic Stress
would not have been possible. Network and the National Center for PTSD, 2006.
9. Hobfoll SE, Watson P, Bell CC, et al.: Five essential elements
Michelle E. Alto, PhD, Medical University of South Carolina, Charleston, of immediate and mid-term mass trauma intervention: Empirical
South Carolina; now at: Department of Mental Health, Johns Hopkins evidence. Psychiatry 2007; 70(4): 283-315.
Bloomberg School of Public Health, Baltimore, Maryland. ORCID: 10. Berkowitz S, Bryant R, Brymer M, et al.: Skills for Psychological
https://orcid.org/0000-0002-9408-1299. Recovery. Washington, DC: National Center for PTSD and the
National Child Traumatic Stress Network, 2010.
Andel V. Nicasio, PhD, Mental Health Disparities and Diversity Program, 11. Harris D, Wurie A, Baingana F, et al.: Mental health nurses and
Department of Psychiatry and Behavioral Sciences, Medical University disaster response in Sierra Leone. Lancet Glob Heal. 2017; 6(2):
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Health Prep. 2018; 13(1): 18-23. Implementation of a multi-phase, trauma-focused intervention
5. Seballos F, Tanner T, Tarazona M, et al.: Children and Disasters: model post-Hurricane Maria in Puerto Rico: Lessons learned from
Understanding Impact and Enabling Agency, Brighton, England: the field using a community based participatory approach. J Fam
Institute of Development Studies. 2011. Strengths 2019; 19(1): 1-41.
22. Orengo-Aguayo R, Stewart RW, Martínez González KG, et al.:
Building collaborative partnerships across professions to imple-
ment trauma-focused cognitive behavioral interventions after
Hurricane Maria in Puerto Rico. Behav Ther. 2019; 42(4): 123-126.

Special Issue on Puerto Rico

Journal of Emergency Management 175
Vol. 19, No. 8

CALL FOR PAPERS

COVID-19 and Mental Health

Journal of Emergency Management (JEM) is preparing a special issue addressing the mental health issues surrounding the COVID-19
pandemic. JEM seeks manuscript submissions focused on the impact of COVID-19 on individuals, organizations and first responders with
a special emphasis on mental health and trauma during the global pandemic.

Additionally, we seek papers that address the confounding nature of COVID-19 as it relates to other disasters faced during the pandemic and the
short and long-term mental health effects on the emergency management profession, the related disciplines and laypersons in your community.

Over the past 12 months, the world has been turned upside down as we encountered COVID-19 and dealt with all the issues adjoining it.
One of the biggest impacts has been on people and their mental health and their ability to deal with the constant onslaught of information
and images. This pandemic struck quickly and left much of the world rocking back on its heels.

The mental health issues inflicted by the COVID-19 pandemic on individuals, families, and communities will not end once a vaccine is
fully distributed. It will be experienced for several years to come. “Trauma not transformed is trauma transferred.” The speed at which this
pandemic arrived on the scene and the apparent lack of attention to the mental health needs of those suffering through this pandemic has
created a recipe for continued distress. There is a clear need for encouraging collaboration and finding ways to address these issues.

Journal of Emergency Management invites manuscripts directly related to the impact of the COVID-19 pandemic.
We are particularly interested in the following areas.

• Trauma and Resilience in the Wake of COVID-19
• Mental Health and Psychosocial Support in Emergency Settings
• Mental Health Care for Emergency Management and Affiliate Professions
• First Responder and Front-line Impacts
• Disparities in Mental Health Services and Outcomes
• Social and Mental Health Problems in Global and/or Domestic Settings
• Compassion Fatigue, Depression and Anxiety
• Lockdown Fatigue, Social Isolation and Confinement
• Suicide Rates and Prevention During and After the COVID-19 Pandemic
• Managing Staff and Laypersons with Comorbid Substance Use Disorders
• Researching and Retooling Emergency Messaging and Communication to Reduce Stress
• COVID-19 and Nationwide Protests
• Global Mental Health and International Impacts
• Secondary Trauma
• Serial Traumatization from Broadcast and Social Media and Rationalization/Sensemaking
• Patients Suffering from Psychiatric Disorders and/or Lack of In-Person Caregiver Access
• Vulnerable Populations
• Pandemic Planning
• Mental Health Care for Emergency Management and Affiliate Professions
• We will work collaboratively with IAEM and their #IAEMSTRONG campaign
• We will consider any manuscript that creates/delivers tools to address items above

Review Process: We will conduct a quick initial review of submissions to assure a fit with the type of articles published in this special
issue. Those manuscripts selected for further consideration will undergo an accelerated peer review and be fast-tracked for publication if
accepted. Authors will be expected to revise manuscripts promptly. Our goal is to get excellent papers dealing with the topics above into
the hands of people who need additional tools to address the mental health aspects of COVID-19. If you want to be considered for the pool
of reviewers for this special issue, please send an email of interest and if available, your CV or short resume to [email protected].

Manuscript Submission: Manuscript should be submitted directly to the Journal of Emergency Management email box at [email protected].
Note this is different than our traditional manuscript peer-review system. Please include a cover letter with full contact details.

Deadlines: Manuscript submissions will be accepted through the end of Q4-2021 and will be placed in the special issue of our online edi-
tion of JEM.

Article Types: We will review articles across the spectrum as original papers, research, best practices, creative solutions, short stories, training,
brief communications, short reviews of existing programs as well as creative mental health management, coping and stress reduction original
papers. Additional documented modalities for managing the topics above will be reviewed with the goal of sharing useful cutting edge tools to
improve and/or address mental health of colleagues and laypersons in your protection. We are happy to preview any submissions.

Article Length: Our traditional article length limit is 3500 words. We will address length limitations on a per article basis.

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13261 09/15/21 Rev.C

JEM Six months after Maria: A post-hurricane examination
of mental health and associated risk factors
in older Puerto Ricans

Jani L. Swiatek, BS
Joseph P. Corcoran IV, BA
Frederick V. Ramsey, PhD

Nina T. Gentile, MD

ABSTRACT persist for years after the acute disaster has ended.1
In addition to causing structural damage to roads
Following Hurricanes Irma and Maria in and other infrastructure, disasters have the potential
September 2017, there were elevated rates of depres- to cause a variety of sequelae including death, physi-
sion and suicide in Puerto Rico. This study evaluates cal harm, and psychological trauma.2-4 According to
mental health in older and elderly Puerto Ricans 6 the World Health Organization (WHO), 4-13 percent
months after the hurricanes and suggests strategies of populations affected by conflicts or emergencies
for improving future psychosocial responses. Patients experience mild to severe mental disorders, including
attending clinics were evaluated for depression schizophrenia, bipolar disorder, depression, anxiety,
(Patient Health Questionnaire [PHQ-9]) and suicide and post-traumatic stress disorder (PTSD) after the
risk (Ask Suicide-Screening Questions [ASQ]) and acute disaster.5
were surveyed about their perceived safety, designated
as a proxy for anxiety. Used in conjunction, PHQ-9 Lack of power and clean drinking water, as well
and ASQ were found to identify a greater proportion of as stress and unsafety in those affected, have been
individuals experiencing adverse mental health effects associated with increased mental health sequelae.
than if each instrument was used in isolation. Patients In the Bronx, following Hurricane Sandy, a dose-
were also surveyed about time to water and electric- response relationship between percentage of residents
ity restoration, and it was found that prolonged time (regardless of age) without power and mental health-
to water restoration was associated with increased related emergency department visits was observed.6
prevalence and severity of depression and decreased In Flint, MI, lack of clean drinking water contrib-
perceived safety. Based on collected patient data uted to increased depression, anxiety, and stress, as
(n = 523), using multiple mental health screening tools identified by a panel of community representatives.
for diagnosis, improving perceptions of home safety or Additionally, distrust and lack of perceived safety
anxiety, and prioritizing water restoration may reduce in their community augmented the mental health
mental health sequelae in the elderly and enhance the impacts of the public health emergency.7 Poor pre-
effect of psychosocial responses following disasters. existing infrastructure in the affected location, lower
socioeconomic status of the population, and delayed
Key words: disaster response, mental health, post-disaster relief efforts have also been shown
Hurricane Maria, depression, water, utility restora- to increase adverse mental health outcomes.6,8 As
tion, elderly, older adults stated by Topping and Schwab,9 effective post-disas-
ter responses must be informed by historical observa-
INTRODUCTION tion and data and the key to improving mental health
outcomes is improving these responses.10,11 Based on
Disasters secondary to natural hazards have
diverse and far-reaching consequences that often

DOI:10.5055/jem.0635 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 177

clinic patient surveys and clinical assessments, we ship off the coast of San Juan, provided inpatient
seek to offer data-driven, actionable items that can be and outpatient services to 35 patients over a 43-day
addressed during disaster recovery to lessen mental period.10,23 For the towns most damaged by Maria,
illness, especially in the elderly. many of which are separated from San Juan by both
distance and unstable roadways, the federal mental
Mental health impacts have the potential to health response was extremely limited.22,24
be particularly severe in older and elderly popula-
tions.12,13 This might be explained by a poor state Considering prior studies that have identified
of health predisaster, decreased mobility overall,14 lack of power, clean water, and safety as markers for
and an increased sense of loss following disaster- poor mental health effects following disasters as indi-
related injury or destruction.13,15 However, there is vidual entities, we report on their collective impact
considerable debate in the literature about whether on older adults in Puerto Rico after Hurricanes Irma
older adults fare better or worse in these scenarios. and Maria. This study examines rates and severity
Knight et al.16 found that adults aged 55-75 dem- of post-disaster mental illness (depression, suicidal-
onstrated a decreased level of emotional distress ity, and perceived safety as a proxy for anxiety) in a
following an earthquake compared to their younger convenience sample of adult clinic attendees (age ≥ 18;
counterparts (age 30-54). Kato et al. noted decreased mean age 60.2 ± 14.8) within five communities in
post-traumatic stress symptoms in those ≥60 years southeast Puerto Rico, 6 months after Hurricanes
versus those < 60 years at 8 weeks post-earthquake.17 Irma and Maria.
Because of the potentially increased vulnerability of
the elderly to mental illness post-disaster, as well as METHODS
the lack of consensus in the literature, it is important
to continue studying the emotional toll of disasters on In March 2018, 6.6 months after Hurricane Maria
the elderly. made landfall in Puerto Rico, a team of 19 medical
students and physicians from Temple University’s
The response to Hurricanes Irma and Maria strik- Emergency Action Corps (TEAC) held mobile clinics
ing Puerto Rico in September 2017 offers a unique in five Puerto Rican towns (Figure 1). Clinics were
microcosm to examine post-disaster mental illness held for 1 day in Arroyo, Maunabo, Patillas, Yabucoa,
in older adults. In early September, Hurricane Irma and Vieques—southeastern towns chosen based on
skirted Puerto Rico’s northeast coast and caused over their proximity to Hurricane Maria’s path and their
one billion dollars of damage to the island’s roads, relative isolation from San Juan, the epicenter of
water supply, and electrical grid.18 In the 11 years Puerto Rico’s disaster response efforts. In addition
prior to Hurricanes Irma and Maria, Puerto Rico’s to TEAC’s team, approximately 35 Puerto Rican
infrastructure lacked stability, in that it was more medical professionals (including doctors, medical stu-
than $70 billion in debt and was in the midst of an dents, interpreters, and nurses) volunteered at the
economic recession.19 Hurricane Maria made landfall clinics each day. Clinics included stations for triage,
on Puerto Rico’s southeast coast 2 weeks after Irma, vitals, general medicine consultations, a mobile phar-
and its effects were amplified because it followed so macy, social workers, and various medical special-
closely in Irma’s footsteps, before any recovery had ties. Referral to other specialists such as dermatol-
occurred.20 ogy, gynecology, and cardiology varied based on the
availability of the volunteer physicians. Physicians
In the months after Hurricane Maria, in addi- were either Spanish-speaking or were paired with
tion to a staggering death toll with >15-fold as many an interpreter. No specific recruitment efforts were
deaths as contemporaneous hurricanes, Harvey and employed—data are from the convenience sample of
Irma, combined, local governments reported increased patients who attended the clinics and completed their
rates of suicide and depression across the island.21,22 charts (N = 587). Only patients ≥ 18 years old were
The federal mental health response, a nine-person included in this analysis (n = 523).
mental health team on the USNS Comfort medical

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178 Journal of Emergency Management
Vol. 19, No. 8

Figure 1.  Paths of Hurricanes Irma and Maria, and post-disaster water and electricity restoration in southeast-
ern Puerto Rico. (A) The approximate trajectories of Hurricanes Irma and Maria displayed on a map of Puerto
Rico. Towns where clinics were held are shown with colored circles and were chosen based on proximity to
where Maria made landfall and relative isolation from relief efforts based in the capital city of San Juan ( ).
(B) The average number of days that citizens in each town went without water restoration () and electric-
ity restoration (∆) are displayed. For patients whose water and power had not been restored at the time of the
clinics (5.1 and 26 percent, respectively), restoration dates were treated as the maximum restoration latency
(200 days, 6.6 months). Towns are displayed vertically based on prevalence of clinical depression 200 days (6.6
months) after Hurricanes Irma and Maria.

Instruments comfort given the significant structural damage after
Validated screenings for depression and suicide the hurricanes. Upon review of the dataset, it became
clear that patient safety may have broader applica-
risk were conducted with every patient to assess tions as a surrogate for mental health. For example,
psychiatry needs. The Patient Health Questionnaire the PROMIS Emotional Distress-Anxiety: Short Form
(PHQ-9) is a nine-question screening tool used to includes six out of seven symptoms that may over-
determine whether a patient was depressed, and also lap with feelings of unsafety at home—fear, anxiety,
to evaluate disease severity with a maximum score of worry, nervousness, uneasiness, and tension.28 While
27 and scores of 0, 5, 10, 15, and 20 indicating minimal, this is an imperfect measure, this patient-centered
mild, moderate, moderately severe, and severe depres- assessment of safety may have value in both assess-
sion, respectively.25,26 The Ask Suicide-Screening ing patients’ mental health after disasters and iden-
Questions (ASQ) tool is a four-question assessment of tifying relief actions, rendering it crucial to include
suicide risk that evaluates both presence of suicidal in this analysis. Additionally, in order to contextual-
ideation and degree of severity.27 PHQ-9 and ASQ ize the relief effort, patients were surveyed about
assessments were offered in Spanish, either verbally whether their water and electricity had been restored
or as written surveys, based on patient preference. and were asked to estimate how long they had gone
At-risk patients (PHQ-9 ≥ 10 and/or ASQ ≥ 1) were sub- without each utility.
sequently seen by a psychiatrist and provided options
for long-term follow-up care. If patients were deemed Survey
an imminent risk to themselves or others, they were All patient chart information, including nonmedi-
immediately supervised by a medical professional and
were able to be transported to a hospital, if necessary. cal survey questions, was collected for the purpose of
patient treatment, real-time quality improvement,
Patients were also asked whether they felt safe in and assessment of current environmental conditions.
their homes, which was included to assess patients’

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Journal of Emergency Management 179
Vol. 19, No. 8

However, during the clinics, patient response patterns SAS® 9.4 (SAS Institute, Cary, NC). Statistical signifi-
were identified, urging our team to pursue further cance was defined as p < 0.05.
analysis of the data. All survey results were recorded
on paper forms, which were deidentified and ana- RESULTS
lyzed as a retrospective chart review. This study was
deemed exempt from IRB review for not meeting the Clinics were held in five towns in Puerto Rico
regulatory definition of Human Subjects Research from March 24 to April 1, 2018, about 200 days (6.6
(Temple University IRB, 2018). months) after Hurricanes Irma and Maria (Figure 1).

Statistical analyses Sample
Statistical analyses were conducted on the dei- Data were collected from a convenience sample of

dentified data of all clinic participants ≥18 years old patients who attended the clinics, and 587 complete
who completed a patient survey. Given that this was patient charts were obtained in total. Only charts
primarily a humanitarian relief project, survey data from adult patients (≥18 years old) were used in the
were collected as part of a general quality monitor- analysis (n = 523): Arroyo, 91; Maunabo, 110; Patillas,
ing initiative secondary to the primary relief focus. 141; Vieques, 95; Yabucoa, 86. The mean patient age
As such, the specific statistical analyses described was 60.2 years ± 14.8, with 69 percent female patients
later were identified post-hoc in order to realize (Table 1).
maximum benefit from this data relative to future
relief projects. Mental health
Depression, suicidality, and perceived lack of
Survey and clinical data included both continu-
ous and categorical variables. For continuous data, safety as a proxy for anxiety were used to gauge post-
descriptive statistics including mean, standard devia- disaster mental health. The PHQ-9 depression assess-
tion (SD), standard error of the mean, median, ment detected moderate to severe clinical depression
and interquartile range were prepared, and number (PHQ-9 score ≥ 10) in 20.6 percent of patients (n =
and frequencies (percentages) were also prepared 102), with an average score of 13 in the depressed
for categorical data. Selected continuous variables group (maximum score: 27). The ASQ suicide risk
were transformed into categorical variables based on assessment detected suicidal ideation in 9.9 percent
accepted clinical criteria. For example, PHQ-9 score of patients (n = 49), and 14.5 percent of patients felt
was treated as both a binary measure of depression unsafe in their homes (n = 69). Many patients met
status and as a discrete variable measuring depres- criteria for multiple mental illnesses, including six
sion severity. Depression, suicide risk, and perceived patients who were depressed, suicidal, and felt unsafe.
lack of safety were used as proxies for mental illness, Of note, the average PHQ-9 score for these patients
with suicide risk and perceived safety analyzed as was 17.0 (the highest of all subsets), compared with
binary variables. For analyses comparing patients an average score of 3.4 in patients who were neither
with different combinations of mental health s­ equelae, depressed, suicidal, or feeling unsafe (Figure 2). There
ie, depressed and suicidal vs. just depressed, only was significant overlap between PHQ-9-diagnosed
patient data with responses for all three conditions depression and ASQ-diagnosed suicidality (p < 0.001).
(depression, suicidal ideation, and unsafety) were The average PHQ-9 score of concurrently depressed
analyzed. Continuous data were analyzed using the and suicidal patients was 16.9, compared with an
two-sample t-test or ANOVA. Pearson’s χ2, Fisher’s average score of 5.4 for all patients. However, only 28
exact, or Mantel–Haenszel χ2 tests were used to com- of the 49 suicidal patients (57.1 percent) were diag-
pare proportions amongst categorical variables. Time- nosed as depressed by the PHQ-9 (Table 2). PHQ-9
to-event data were analyzed using Kaplan–Meier scores varied by town, with Patillas having the high-
estimators. Statistical analyses were conducted using est average score of 6.9, compared with the other
towns whose average scores ranged from 4.6 to 5.4

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180 Journal of Emergency Management
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Table 1. Demographics of patients attending free clinics held in five towns
in Puerto Rico, 6 months post-disaster

Variable Overall Arroyo Maunabo Patillas Vieques Yabucoa p-Value

Patients ≥ 18 523 91 110 141 95 86
years olda

Female sex 361 63 81 88 75 54 0.042*
(69.0 percent) (69.2 percent) (73.6 percent) (62.4 percent) (78.9 percent) (62.8 percent)

Mean age 60.2 ± 14.8 63.5 ± 11.6 62.6 ± 14.4 59.7 ± 14.7 54.4 ± 16.3 61.1 ± 15.4 <0.001*
(±SD)

2017 median $15,937 $15,689 $17,636 $14,512 $16,261 $15,586
household
incomeb

Depressedc 102 13 13 42 19 15 0.003*
(20.6 percent) (16.7 percent) (12.1 percent) (31.8 percent) (20.2 percent) (18.1 percent)

PHQ-9 score 5.4 ± 5.6 4.9 ± 5.3 4.6 ± 4.8 6.9 ± 6.2 5.4 ± 6.3 5.4 ± 6.3 0.064
(±SD)

Suicidalc 49 6 10 17 12 4 0.299
(9.9 percent) (7.7 percent) (9.4 percent) (12.8 percent) (12.6 percent) (4.8 percent)

Feels unsafe 69 13 17 21 14 4 0.171
(14.5 percent) (16.3 percent) (16.7 percent) (16.0 percent) (16.1 percent) (5.2 percent)

Days without 46.0 ± 49.2 27.7 ± 45.8 48.9 ± 50.7 47.7 ± 48.2 39.7 ± 37.6 68.1 ± 54.7 <0.001*
water (±SD)

Days without 140 ± 47.5 114.2 ± 37 141.8 ± 47 139.3 ± 45.3 132.9 ± 45 174.8 ± 44.3 <0.001*
power (±SD)

aTotal patients sampled was 587, but only patients ≥18 years old were used in analysis (n = 523).
bValues reported are median household incomes from the United States Census Bureau, 2017.
cDepression and suicidality were determined using PHQ-9 and ASQ screening tools, respectively.
*Significant at the 0.05 level.

(p = 0.069). The prevalence of depression in Patillas 17.1 percent, p < 0.001; suicidal: 57.1 percent vs. 16.7
was significantly higher than in other towns: 31.8 per- percent, p < 0.001) and was not associated with town
cent in Patillas versus 12.1-20.2 percent in all other (p = 0.171) (Figure 2). Sex did not correlate with
towns (p = 0.003) (Figure 1). depression (p = 0.735), suicide risk (p = 0.962), or per-
ceived safety (p = 0.783). Nor were there significant
A total of 14.5 percent (n = 69) of patients differences in the ages of groups with any mental
reported feeling unsafe in their homes 6 months illness versus those without (depressed, p = 0.485;
after the hurricanes. While feeling unsafe does not suicidal, p = 0.902; unsafe, p = 0.455) (Table 2).
describe a specific psychiatric condition, it encom-
passes six out of seven questions from the PROMIS Restoration of utilities
Emotional Distress-Anxiety: Short Form, rendering it On average, patients waited 46 ± 49.2 days for
a valuable alternative in the absence of more specific
data. Feeling unsafe or suicidal was associated with water to be restored, and 140 ± 47.5 days for power
higher rates of depression (unsafe: 38.8 percent vs. to be restored ( ± SD). Notably, this sample includes

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Journal of Emergency Management 181
Vol. 19, No. 8

Figure 2.  Levels of mental health sequelae 200 days Yabucoa residents were reported without water and
after Hurricanes Irma and Maria. Mental health electricity for the longest time (water, 68.1 days;
was evaluated by surveying for clinical depression power, 174.8 days), followed by Maunabo (water, 48.9
(PHQ-9), suicidal ideation (ASQ), and perceived lack days; power, 141.8 days).
of safety in five Puerto Rican towns, approximately
200 days after Hurricane Maria. (A) Depression var- In the depressed group, there was a significantly
ied significantly by town (p = 0.003), but there was no longer time without water (59.2 days) versus those
significant difference in suicidal ideation (p = 0.299) who were not depressed (42.8 days) (p = 0.007). A
or perceived safety (p = 0.171) across towns. (B) Only similar correlation was noted when comparing days to
patients with complete data for depression, suicide water restoration versus patients’ perceived safety at
risk, and perceived safety were included in this por- home, with the “unsafe” group waiting a significantly
tion of the analysis (n = 453). Overlapping areas rep- longer period for water restoration than the “safe”
resent the number of patients (n) and average PHQ-9 group (60.3 days vs. 44.0 days; p = 0.012). However,
score (±SD) (italicized) for different combinations of there was no difference in days without water between
post-disaster mental health sequelae. Circle area is the suicidal and nonsuicidal patients (p = 0.143). The
not representative of subgroup size. length of time before power was restored was not
associated with depression (p = 0.608), suicide risk (p
patients who did not have water (n = 26, 5.1 percent) = 0.838), or perceived home safety (p = 0.268).
or power (n = 132, 26.0 percent) 200 days, or 6.6
months, post-disaster. The exact restoration dates In accordance with Kroenke and Spitzer,25,26
for these participants were not measured beyond the PHQ-9 scores were divided by depression severity:
time of the clinics. The length of time before water 0-4 (none to minimal); 5-9 (mild); 10-14 (moderate);
was restored differed by town (p < 0.001), as did the and ≥15 (moderately severe to severe). Similarly, the
time before power was restored (p < 0.001) (Figure 1). latency period to water restoration was divided into
groupings of 0-15, 16-30, 31-60, 61-120, and >120
days to achieve groups with approximately equal
sample sizes. A Mantel-Haenszel analysis of the
PHQ-9 severity categories versus latency periods for
water restoration demonstrated that the patients
who had their water restored quickly suffered from
less severe depression, whereas patients waiting
>120 days suffered from worse clinical depression
(p < 0.001). At 0-15 days, 2.5 percent of patients had a
PHQ-9 score ≥ 15 (moderately severe to severe depres-
sion), while at > 120 days, 15.9 percent had a PHQ-9
score ≥ 15. A Kaplan–Meier analysis further supported
these findings by showing that a larger proportion of
those who were clinically depressed lacked water at
any given time point (p = 0.005) (Figure 3).

The results of the same analyses comparing days
to power restoration and PHQ-9 severity category
did not show any significant relationships (Mantel–
Haenszel: p = 0.996; Kaplan–Meier: p = 0.835).

DISCUSSION

The goal of this analysis is to identify aspects of
disaster response that can be targeted to improve

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182 Journal of Emergency Management
Vol. 19, No. 8

Table 2. Relationships of PHQ-9 scores, depression, power and water restoration,
and age with patient subgroups

Variable n Mean PHQ-9 p-Value Depressed Days w/o Days w/o p-Value Mean age p-Value
(±SD) (±SD) p-Value water p-Value power (±SD)
(±SD)
(±SD)

Overalla 494 5.4 ± 5.6 20.6 percent 46.0 ± 49.2 140 ± 47.5 60.2 ± 14.8

Depressed 102 13.0 ± 6.3 <0.001* 100 percent <0.001* 59.2 ± 56.6 0.007* 138.2 ± 48.2 0.608 60.3 ± 11.8 0.485

Non-­ 392 3.5 ± 3.3 0 percent 42.8 ± 46.4 141.2 ± 47.9 59.9 ± 15.7
depressed

Suicidal  49 11.6 ± 7.9 <0.001* 57.1 percent <0.001* 54.0 ± 55.5 0.143 138.4 ± 51.2 0.838 61.3 ± 12.0 0.902

Non-­ 445 4.8 ± 4.9 16.7 percent 45.3 ± 48.1 140.8 ± 47.7 59.8 ± 15.2
suicidal

Unsafe  67 8.3 ± 6.4 <0.001* 38.8 percent <0.001* 60.3 ± 56.3 0.012* 133.2 ± 49.8 0.268 59.7 ± 15.3 0.455

Safe 390 4.9 ± 5.2 17.1 percent 44.0 ± 47.2 141.0 ± 47.5 61.8 ± 13.0

Female 340 5.5 ± 5.5 0.280 20.2 percent 0.735 46.0 ± 49.4 139.0 ± 48.7 58.9 ± 15.1 <0.001*

Male 154 5.2 ± 5.8 21.6 percent 45.9 ± 48.7 142.3 ± 44.6 63.2 ± 13.8

aColumns may not add to total patients due to missing data.
Plus or minus values represent a single standard deviation.
*Significant at the 0.05 level.

mental health outcomes in the elderly. Successfully does, in fact, negatively impact mental health post-
identifying factors, such as mental illness, that disaster. In this study, no specific younger age group
impede post-disaster recovery are critical in improv- was sampled for comparison, and likely, because of the
ing outcomes.9 lack of age diversity, there is no statistically signifi-
cant difference in age between those without mental
Old age and mental illness illness after the hurricanes versus the groups experi-
Importantly, this study population was composed encing depression, suicidal ideation, or feeling unsafe
(Table 2). An additional contributor to the widespread
mainly of elderly patients, with a mean age of mental health damage caused by Hurricanes Irma
60.2 ± 14. According to Ticehurst et al.14 and Jia et and Maria is likely the prolonged recession that the
al.,13 older age is associated with worse mental health territory was experiencing in the 11 years prior to
following a disaster. The results of this study reflect these hurricanes. This reflects a poor infrastructure,
prevalent mental illness following Hurricanes Irma which suggests a decreased ability to execute an opti-
and Maria—20.6 percent were depressed, 9.9 percent mal recovery effort, leading to more pervasive mental
were suicidal, and 14.5 percent felt unsafe (a proxy for health impacts.8
anxiety). This is in comparison to the following rates
of mental illness in the elderly in the United States: Utility of multiple mental illness
depression, 7.7 percent (≥55 years old); suicidal idea- screening instruments
tion, 6-7 percent (older adults); and lifetime anxiety,
7.6-12.7 percent (>50 years old).29-31 The elevated lev- The PHQ-9 was a valuable method for evaluating
els of mental health sequelae in older Puerto Ricans the post-disaster depression levels, but the PHQ-9
post-hurricane support the argument that old age score alone was not reliable in predicting suicide risk.

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Figure 3. Post-disaster depression survival curves based on water and electricity restoration. Kaplan–Meier
survival curves of post-disaster clinical depression partitioned by days without water restoration (A), and
days without electricity restoration (B). These data were assessed as time-to-event data, with the event being
either water or electricity restoration. For individuals who did not have water or power restored at the time
of the questionnaire (>200 days without water and/or electricity), responses were censored at 200 days. Mean
days without utilities are indicated in the boxplots by the black dot. (A) At any given time, a larger proportion
of respondents who were clinically depressed did not have water compared to nondepressed respondents (p =
0.005). (B) There was no difference between the depressed and nondepressed groups in terms of days without
electricity (p = 0.835).

While there was a statistically significant relation- were more than doubled in the unsafe group and more
ship between depressed PHQ-9 score and positive than tripled in the suicidal group, which further sup-
ASQ suicide risk (p < 0.001), only 28 of the 49 suicidal ports a relationship between these conditions. Because
individuals were detected as clinically depressed via of the complex interrelationships among the mental
the PHQ-9. This demonstrates the importance of illness states, we postulate that by intervening on just
including multiple mental health screenings in a post- one of them, we might be able to reduce the amounts
disaster population to ensure that no high-risk indi- of depression, suicidality, and anxiety overall.
viduals are missed. Additionally, those patients who
screened as positive for both depression and suicide Subgroup analysis: Patillas
risk had an average PHQ-9 score of 16.9, three times Of the five towns examined, Patillas had the high-
higher than the average score for the sample and five
times higher than those who did not demonstrate any est average PHQ-9 score (6.9), rate of depression (31.8
mental illness. Patients who met criteria for all three percent), and rate of suicidal ideation (12.8 percent).
mental illnesses had a PHQ-9 score of 17, the highest Since baseline mental health levels are unknown, it
among all subgroups. This indicates a greater disease is unclear whether the discrepancies between Patillas
severity and suggests that these patients may benefit and surrounding towns are long-standing, were exac-
from higher levels of care than those who are either erbated by the hurricanes, or influenced by both.
depressed, suicidal, or feeling unsafe.25,26 Compared However, these discrepancies might be explained
with those without mental illness, rates of depression by Patillas’ remoteness compared with other towns,
difference in population demographics or other

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predisposing risk factors among residents. Increased illness rates are correlated with water restoration,
vulnerability may also be correlated with the income emphasizing the negative impact of this delay and
differential between Patillas and the four other towns. highlighting the effect that efficient repair may have
The average median income in Patillas was $14,512 on rates of depression and anxiety.
in 2017, which is 9 percent or $1,435 lower than the
average median income of all five towns.32 Lower Water restoration latency may serve as a predictor
income areas have been shown to have worse mental not only of depression risk but also of depression sever-
health outcomes post-disaster.6 More work needs to be ity. Depressed patients waited 16.4 days longer to have
done to explore specific risk factors, such as sense of their water restored than those who were not depressed,
loss, degree of chronic illness, and physical immobil- and there was a larger proportion of depressed patients
ity, that may justify Patillas’ especially poor mental without water at a given time than those who were not
health outcomes.15 depressed (p = 0.005). Similarly, percentages of severe
PHQ-9 scores (≥15) were increased in those who waited
Considering the potential impacts of age ≥ 60 >120 days for water versus those who waited ≤15 days
and lower income on post-disaster mental health, (15.9 percent vs. 2.5 percent). However, there was no
it remains important that rescue efforts consider association between power restoration and depression
the unique vulnerabilities of different towns when rates (p = 0.608) or PHQ-9 severity (p = 0.996), in con-
identifying at-risk populations and allocating mental trast to findings in similar studies by Lin et al.6 This
health aid following a disaster. suggests that the absence of running water may be
more mentally taxing than the absence of power, and
Restoration of utilities and mental illness that prioritizing water restoration may improve post-
Many individuals went for months without power disaster mental health.

(140 ± 47.5 days) and water restoration (46 ± 49.2 CONCLUSIONS
days). The average length of time without these
necessities is a conservative estimate since 26.0 per- Overall, these results demonstrate a high level of
cent of respondents were still without power and 5.1 mental illness among the elderly following Hurricanes
percent were still without water at the time of the Irma and Maria that was associated with long delays
clinics. This study establishes a relationship between in water restoration. This is concordant with the
time to water restoration, and both perceived safety devastation described by other groups who report an
at home, functioning as a proxy for anxiety (p = increase in PTSD and depression, a severely under-
0.012), and clinical depression (p = 0.007). Based on estimated death toll, and a more pronounced mental
recommendations from our supervising psychiatrist, illness burden in the elderly—all of which reflect
an anxiety measure was excluded from the patient insufficient administrative assessment of the recovery
charts in order to reduce the amount of paperwork effort.15,18,19 Complementing these prior studies, we
required from participants and because depression suggest various interventions that may lessen adverse
and suicidal ideation have more devastating and mental health effects in the elderly post-hurricane.
actionable short-term effects. We identified post-hoc This includes using multiple mental illness screening
that reduced safety may correlate with up to six out of methods for diagnosis, improving perceptions of home
seven questions on the PROMIS Emotional Distress- safety or anxiety, and prioritizing water restoration,
Anxiety: Short Form, rendering unsafety an accept- with the objective of mitigating the post-disaster
able approximation for levels of anxiety in this popu- mental health burden and promoting more targeted
lation, in the absence of a validated screening tool. psychosocial responses following large-scale disasters.
Anecdotally, many patients cited structural damage
to their homes as the source of their anxiety, which, While we report on the collective impact that
according to Oriol et al.,15 is related to a sense of loss water restoration latency, old age, and low income
and worse mental health outcomes. Overall, mental may have on post-disaster mental health, we hope
that this serves as a data-driven call to action for

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emergency management systems to “incorporate les- various areas in which more research should be
sons learned from past disasters” so that future done. This includes soliciting a comparison group
groups will be spared from the suffering endured by of younger individuals and evaluating their mental
so many elderly Puerto Ricans after Hurricanes Irma health after a similar disaster, investigating the rela-
and Maria.8 tionship between anxiety and lack of home safety,
and further characterizing the demographic differ-
LIMITATIONS ences between Patillas and the other towns studied.
Future work examining more specific demographics
These data are representative of those most severely in concurrently depressed and suicidal individuals
affected by the hurricanes based on clinic location but who were shown, in this study, to have more severe
may not be representative of all Puerto Ricans since depression scores may provide ways to identify and
damage varied widely across the island. Data collection target high-risk persons for treatment post-disaster.
was also limited to patients who were physically able
and mentally willing to travel to the clinics. This raises ACKNOWLEDGMENTS
concern that the most vulnerable were not sampled, The Temple Emergency Action Corps (TEAC) service trip
and that the true state of mental health may be worse and free clinics were funded by a generous grant provided by the
than observed from this sample. Furthermore, our eval- Greenfield Foundation. Temple University’s Episcopal Hospital
uation of feelings of unsafety in the home as a proxy also provided invaluable support in the form of supplies donations.
for anxiety is imperfect, in that it was derived post- Dr. Natalia Ortiz offered exceptional psychiatric guidance prior to
hoc after correlations between unsafety and increased and during the clinics and our other Temple University Hospital
depression and suicide were noted and is based broadly physician volunteers, Dr. Kisha Martin, Dr. Laura Martin, and Dr.
on interpretation of the PROMIS Emotional Distress- William Greenfield, provided mentorship and guidance throughout.
Anxiety: Short Form. It would require specific valida- We would like to give a special thank you to our fellow student co-
tion studies comparing lack of safety in the home with coordinator, Christina G. Lopez, who contributed extensive time and
anxiety scores in order to render it an appropriate effort to ensure the success of this mission and connected our team
measure to use in future studies. with many groups in Puerto Rico. We would also like to thank our
collaborators in Puerto Rico, Dr. Ruth Reyes and Dr. Daisy Quiros,
Additionally, this sample reflects mainly an older who helped immensely with the organization and planning of this
population (mean age of 60.2 ± 14), so the correlations relief effort. Without these groups and individuals, this outreach
seen in this study are not generalizable. This study would not have been possible.
also lacks a specific comparison group of younger
individuals due to our samples being collected from Jani L. Swiatek, BS (co-first author), Lewis Katz School of Medicine,
a convenience sample of patients self-presenting to Temple University, Philadelphia, Pennsylvania. ORCID: https://orcid.
the clinics. A comparison group would allow for more org/0000-0002-5893-8152.
concrete conclusions to be drawn regarding mental
illness in the elderly population after disasters. Joseph P. Corcoran IV, BA (co-first author), Lewis Katz School of
Medicine, Temple University, Philadelphia, Pennsylvania.
Finally, like many disaster-response analyses,
this study lacked predisaster baseline mental ill- Frederick V. Ramsey, PhD, Department of Clinical Sciences, Lewis Katz
ness levels and is, therefore, limited by the temporal School of Medicine, Temple University, Philadelphia, Pennsylvania.
ambiguity between disaster exposure and disaster
consequence. Nina T. Gentile, MD, Lewis Katz School of Medicine, Temple University,
Philadelphia, Pennsylvania.
FUTURE DIRECTIONS
REFERENCES
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US federal response to hurricane disaster in Texas and Florida
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Fact Sheets. Geneva: World Health Organization, 2019.

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6. Lin S, Lu Y, Justino J, et al.: What happened to our environment 19. Gay H, Santiago R, Gil B: Lessons learned from Hurricane
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Chicago, IL: American Planning Association, 2014; pp. 42-59. sion aboard the USNS comfort during humanitarian operations in
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13. Jia Z, Tian W, Liu W, et al.: Are the elderly more vulnerable to 26. Kroenke K, Spitzer RL: The PHQ-9: A new depression diagnos-
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943-951. (PROMIS Emotional Distress-Anxiety Short Form). Evanston, IL:
15. Oriol W: Chapter 3: Older persons in disasters. In Nordboe PROMIS Health Organization (PHO) and PROMIS Cooperative
D (ed.): Psychosocial Issues for Older Adults in Disasters. North Group, 2008-2012.
Bethesda, MD: US Department of Health and Human Services, 29. Shim R, Baltrus P, Ye J, et al.: Prevalence, treatment, and con-
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Aging. 2000; 15(4): 627-634. Nursing assessment of suicide risk. Issues Ment Health Nurs. 2006;
17. Kato H, Asukai N, Miyake Y, et al.: Post-traumatic symptoms 27(4): 355-370.
among younger and elderly evacuees in the early stages follow- 31. Centers for Disease Control and Prevention and National
ing the 1995 Hanshin-Awaji earthquake in Japan. Acta Psychiatr Association of Chronic Disease Directors: The State of Mental Health
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18. Cangialosi JP, Latto AS, Berg R: Hurricane Irma (AL112017); Decatur, GA: National Association of Chronic Disease Directors, 2008.
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Center, 2018. factfinder.census.gov. Accessed November 14, 2019.

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Notes

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JEM Case study of VA Caribbean Healthcare System’s
community response to Hurricane Maria

Tamar Wyte-Lake, DPT, MPH
Susan Schmitz, MAIDP

Cosme Torres-Sabater, RN, MEP, CHCM
Aram Dobalian, PhD, JD

ABSTRACT federal partner, and services provided directly to the
Puerto Rican community.
Background: Hurricane Maria, which hit
Puerto Rico in 2017, catastrophically impacted infra- Discussion: Recent disasters have revealed that
structure and severely disrupted medical services. coordinated efforts between multidisciplinary agen-
The US Department of Veterans Affairs Caribbean cies can strengthen communities’ capacity to respond.
Healthcare System (VA CHCS), which serves approxi- This case example demonstrates how a VA hospital
mately 67,000 patients and has most of its facilities not only continued serving its patients but, with the
on the island of Puerto Rico, was able to successfully support from the greater VA system, also filled a wide
maintain operations after the hurricane. As a part of variety of requests and resource gaps in the commu-
the larger VA system, VA CHCS also has a mission to nity. Building relationships with local VAMCs can
support “national, state, and local emergency manage- help determine how VA could be incorporated into
ment, public health, safety and homeland security emergency management strategies. In considering
efforts.” The objective of this study is to better under- the strengths community partners can bring to bear,
stand the ways VA and its facilities meet this mission a coordinated regional response would benefit from
by exploring how VA CHCS acted as a community involving VA as a partner during planning.
resource following Hurricane Maria.
Key words: Hurricane Maria, Puerto Rico, US
Methods: This study investigated experiences of Department of Veterans Affairs, collaboration
five employees in critical emergency response positions
for VA CHCS, Veterans Integrated Service Networks INTRODUCTION
(VISN) 8, and the Office of Emergency Management.
All respondents were interviewed from March to July As one of the US Department of Veterans Affairs’
2019. Data were collected via semistructured inter- (VA’s) statutory missions, the Veterans Health
views exploring participants’ experiences and knowl- Administration (VHA) is uniquely tasked after a
edge about VA’s activities provided to the community disaster with both planning for and acting to ensure
of Puerto Rico following Hurricane Maria. Data were continued services to its veteran patients, while also
analyzed using thematic and in vivo coding methods. supporting “national, state, and local emergency man-
agement, public health, safety and homeland security
Results: All respondents underscored VA’s pri- efforts.”1 The quote from a VA emergency manager
mary mission after a disaster was to maintain conti- highlights what is generally referred to as the “Fourth
nuity of care to Veterans, while concomitantly describ- Mission,” to help the community respond to disasters:
ing the role of VA in supporting community recovery.
Three major themes emerged: continuity of operations . . . as a part of our regular process, every
for the San Juan VA Medical Center (VAMC) and its year we invite all the medical centers and
affiliated outpatient clinics, provision of services as a agencies to participate in our VA Household

DOI:10.5055/jem.0536 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 189

Vulnerability Analysis Meeting, where we Hurricane Maria
discuss our risks and we do an analysis of September 2017 brought the most intense
all the risks, including earthquakes, hur-
ricanes, and we talk about communication Atlantic hurricane to hit Puerto Rico in modern times,
projects and we talk about our prepared- Hurricane Maria.7 This category 4 storm devastated
ness plan. So by inviting the community the island with wind gusts up to 120 mph and nearly
to our house, our medical center, and let 38 in. of rain in some locations.7 It decimated infra-
them know . . . here are our plans. They structure, leaving almost all 3.4 million inhabitants
know about the capabilities of the medi- without power, communication services, or potable
cal center and they know [key staff] and water.8 Roads were obstructed or destroyed by debris
leadership. And they understand that as a and flooding, causing many areas to become inacces-
part of our—even in the three major mis- sible.9 These effects compounded existing infrastruc-
sions that we have—cemetery [through the ture damage caused by Hurricane Irma, which, only
VA’s National Cemetery Administration], 2 weeks prior, had left approximately two-thirds of
benefits [through the VA’s Veterans Benefits the population without power and one-third without
Administration], and healthcare [through clean water.7
VA’s VHA], we also have a fourth mission
of supporting community during a disaster. The catastrophic impact to infrastructure and
So that’s why they can ask for support, and extensive damage throughout the island resulted
we have the responsibility—we try to help in severe disruptions to medical services, extremely
them, because at the end, they also treat limited access to medications, and problems access-
and receive our Veterans in their medical ing healthcare providers.10 Hospitals in Puerto Rico
centers. (DT1) were forced to run exclusively from backup sources of
power and water. Personnel had difficulty getting to
Collaboration is a key component of emergency work, and hospitals were unable to communicate with
management efforts nationwide,2-4 and history has staff.9 The magnitude and scope of Hurricane Maria’s
shown the important role that public–private partner- impact has been described in detail elsewhere,10 yet
ships have served in these collaborative efforts.5 While few publications have examined the direct impacts on
the VHA is a federal public entity, it is in essence com- hospitals and the healthcare infrastructure’s ability
posed of a multitude of healthcare facilities that exist as to respond.9
part of a local community’s healthcare infrastructure.
As such, there is a growing movement of VA Medical Veterans Health Administration and
Center (VAMC) emergency management teams work- VA Caribbean Healthcare System
ing to collaborate with local community agencies and
healthcare coalitions to strengthen preparedness.1,6 The VA CHCS is comprised of the San Juan VA
Traditionally, fulfilling the Fourth Mission has been Medical Center (SJ VAMC) and 10 community-based
translated into supporting healthcare infrastructure outpatient clinics (CBOCs) located throughout Puerto
by providing medical support and being a Federal Rico and the US Virgin Islands. It serves approxi-
Coordinating Center. This investigation explores how mately 67,000 veterans.11 The VA CHCS is part of
the VA’s Fourth Mission as carried out by the VA the nation’s largest integrated healthcare system,
Caribbean Healthcare System (VA CHCS) and the the VHA, which is divided into regional Veterans
larger VA supported the people of Puerto Rico after the Integrated Service Networks (VISNs). The 18 VISNs
devastation of Hurricane Maria, and thereby presents of VHA manage 1,255 healthcare facilities, includ-
a case study of the potential value of public–private ing 1,074 outpatient sites of care within the United
partnerships in the United States. States and its territories.12

Each VAMC is highly dedicated to its own emer-
gency preparedness efforts and is aided by both
the local VISN and through fiscal and personnel

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190 Journal of Emergency Management
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support from VHA’s national Office of Emergency individuals with critical response roles. These addi-
Management (OEM). During disasters, all branches tional respondents were then recruited indepen-
of the VA are activated to manage impacts on veter- dently by the project team via email and phone, with
ans and VA-benefit recipients. OEM and the VISN instruction that only the research team would know
continue to help local VAMCs following a disaster who agreed to participate and that participation was
by identifying needs and distributing resources and voluntary. The interview addressed questions around
personnel. The Fourth Mission is generally initi- the SJ VAMC’s collaborative activities with non-VA
ated upon the authorization of the Robert T. Stafford entities during the 2017 hurricane season, as well
Disaster Relief and Emergency Assistance Act.13 as actions required to support continuity of care
for veteran patients. Probes focused specifically on
As part of the larger VA, the VA CHCS has access Hurricane Maria’s response and recovery due to its
to many resources, whereas private and nonprofit direct impact on Puerto Rico; however, as Hurricanes
healthcare facilities do not. As part of the local com- Irma and Maria occurred close together, comments
munity, it is uniquely situated to apply these assets about Hurricane Irma occasionally arose. In all
at a local level. This case study describes the VA’s cases, one-on-one interviews were conducted in order
efforts to fulfill its missions to support both veteran to allow for confidentiality of respondent informa-
patients—to ensure their continuity of care—and tion. Interviews were conducted either jointly by all
non-Veterans by detailing the role VA CHCS played in authors or by a minimum of the primary author (TW)
Puerto Rico’s response and recovery to the devasting and a secondary author (SS or AD). Interviews were
effects of Hurricane Maria. audio-recorded with the permission of the respondent.

METHODS Analysis plan
Interview recordings were transcribed, and data
Study design
This case study used qualitative interview meth- were analyzed using Atlas.ti (Version 7.0, Atlas.ti
Scientific Software Development, GmbH) using both
ods intended to elicit in-depth sharing of study partic- structural and in vivo coding methods.14 Initial struc-
ipants’ experiences as part of the VA CHCS’s response tural codes were established a priori, based on the
to Hurricane Maria. The VA Greater Los Angeles interview guide. The code list was iteratively revised
Healthcare System’s Institutional Review Board (Los and expanded, based on in vivo coding methods.14
Angeles, CA, USA) approved this study. Authors TW and SS independently coded each inter-
view and resolved discrepancies by consensus.
Setting and sample
The study data were collected by telephone with RESULTS

respondents from VA CHCS, employees from VISN Five respondents in critical emergency response
8, and OEM. The sample was purposively chosen to positions for VA CHCS, VISN 8, and OEM were inter-
represent staff who held emergency management viewed. All respondents played a substantial role in
roles critical to coordinating the VA’s local response in the activities of the VA’s response in Puerto Rico to
Puerto Rico to Hurricane Maria. All respondents held Hurricane Maria. Due to the unique nature of SJ
critical response positions for either the SJ VAMC, VAMC being the local arm of VHA, a federal entity,
VISN 8, or OEM. as well as being located on part of the noncontiguous
United Sates, three major themes related to how the
Data collection methods VA and VA CHCS engaged in collaborative activities
Data were collected through semistructured, with non-VA entities in response to Hurricane Maria
were identified: continuity of operations for the SJ
60-minute telephone interviews with each respond- VAMC and its affiliated outpatient clinics, provision
ent between March and June 2019. Emergency man-
agement personnel were the first point of contact,
and these early respondents identified additional

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of services as a federal partner, and services provided preparedness and response funding and personnel;
directly to the Puerto Rican community. and (3) the dedication of VA employees, who immedi-
ately returned to work as soon as they were able. As
Continuity of operations noted by a respondent:
Respondents underscored that the primary mis-
. . . we were able to continue all operations
sion following the Hurricane was for the VA CHCS and all services to our Veterans in the
to maintain its own continuity of operations and that main facility here in San Juan, and also
this security was essential to being able to provide in all CBOCs . . . And we were able to do it
services to the community-at-large. Although respond- because of our employees and the [DEMPS]
ents reported VA CHCS had prepared for a devastat- volunteers that eventually we received. But
ing hurricane, additional supplies were needed and our employees were very committed to con-
VA CHCS benefitted from being part of the larger VA tinue operations, alternating in different
network as they were able to receive physical sup- shifts. There were two CBOCs that were
port such as mobile medical units, mobile pharmacy completely destroyed, and the next day of
vehicles, tents, water, medical resources, communica- the hurricane, the employees by themselves,
tion support, sterilization resources, etc. Additionally, they set up in front of this clinic and with a
from September through December 2017, VA CHCS table and some tents that we put there, they
received the assistance of 900 medical volunteers, in continued providing services to veterans,
shifts, through VHA’s Disaster Emergency Medical obviously in a minor scale, but obviously
Personnel System (DEMPS) program,15 including receiving veterans and addressing them to
physicians, nurses, maintenance staff, drivers, and the different scenarios onto the main facil-
police officers. As VA CHCS includes both the SJ ity if they needed, as well to screen what
VAMC and associated clinics, including two in the were the needs for them. So I would say
US Virgin Islands, there were multiple facilities that that having that committed—I mean, sup-
required support and monitoring. As noted by one port from our workers was key for that.
respondent:

Something significant that we learned is— Recognizing the hardships employees faced
as we recovered in the first 24 hours after after the storm, VA leadership provided numerous
the catastrophic event, we not only think resources to both employees and their families. A pri-
about the main medical center damage, mary need was addressing the lack of basic utilities
but also what happened with our clin- on the island. As one respondent noted:
ics  .  .  .  The [disaster assessment] teams
arrived and our approach was to reopen Because the facility can have power but if
that clinic in order to provide care to our the employees have their own personal prob-
Veterans as soon as possible. (DT1) lems and they are not emotional healthy to
provide the support to the veterans, prob-
Due to the significant resources the VA was able ably weeks after you open the clinic, you
to bring to bear, VA CHCS was able to maintain will have probably absenteeism of employ-
operations throughout the island in the immediate ees because . . . when they go back to their
days following the hurricane. Respondents attributed houses, they have no power. They don’t
this to (1) significant ongoing preparedness efforts have water. They don’t take showers for
conducted by the local VAMC, including stockpil- days. They don’t have ways to wash their
ing of supplies and running community-wide drills; clothes. They don’t have enough food. So we
(2) support from the greater VA through dedicated were handling the physical damage of the

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facility, but we also needed to supply water officers—in the same facility of the clinic
to the veterans, so the employees, we were providing support to the community and
asking employees if you need to wash your we did that in two of our clinics and that
clothes, send them to the medical center, we was something that we did different and it
will wash them for you. (DT1) was not in our plans and we learned that
that was a significant support to our com-
Federal partner munity during that type of response. (DT1)
As a federal entity, the VA had to balance the needs
As local experts, the San Juan VA team was able
of its internal mission, ie, continuity of care, with its to also facilitate lodging and food in some instances for
external mission, ie, its responsibility to provide sup- personnel from other federal agencies, and even pro-
port and resources to other federal entities and the local vided places to bathe from existing hospital resources.
community. Some of these requirements fell to the local In turn, partner federal agencies helped the SJ VAMC
VAMC, such as fulfilling US Department of Health and deliver medications to the US Virgin Islands by pro-
Human Services (HHS) requests to shelter and sup- viding them with transportation.
port the medical care of non-veteran dialysis patients
from the US Virgin Islands after Hurricane Irma. And Serving the community
some, such as staffing the Federal Medical Station, Due to the severe damage sustained by the island
were determined by VA headquarters staff in DC at the
Emergency Management Coordination Center. of Puerto Rico, many non-VA healthcare agencies
struggled to maintain operations and required a
To coordinate tasks and manage internal and coordinated response to identify issues and poten-
external mission assignments, VA CHCS staff acti- tial assistance. However, SJ VAMC was not initially
vated their Hospital Incident Command Center included with other hospitals in the local community
(ICC) at the SJ VAMC, which was active for almost response; as a federal entity, it was considered to be
7  months. The ICC welcomed representatives from separate from the local healthcare infrastructure.
the Readjustment Counseling Service, Vet Center Therefore, it was not immediately included at the
Program, Veterans Benefits Administration (VBA), and Puerto Rico Incident Command Post, which limited
National Cemetery Administration (NCA) and had an information exchange and hindered smooth collabo-
almost daily presence from HHS personel. The Centers ration in the early stages of the response. To rectify
for Disease Control and Prevention (CDC), HHS, and this, one of the first steps VA CHCS leadership took
others asked the ICC for medical provisions such as was to request that it be included in the local coordi-
pharmaceuticals, space to base field provisions, and nation effort and have representation in the Incident
information about potential outbreaks and infection Command Post. As described by a respondent:
control surveillance. The VA CHCS Incident Command
staff was charged with determining whether and how their hospital association here in Puerto
requests would be filled while ensuring internal needs Rico was facilitating different needs from
to continue veteran services were not impacted. As the different hospitals, local hospitals. So
described by one respondent, supporting federal part- what we saw at the beginning of the first
ner activities and colocating them with VA services probably two or three days was that they
were highly appreciated by the community: were not counting with us as another hos-
pital, so one of the first requests was to
We receive also requests from federal agen- assure that we had presence in all the plan-
cies  .  .  .  one example is that one of our ning and all the resources distribution. In
clinics we have not only is the staff provid- order that—in case that we confront any
ing care to the Veterans but also we have situation, they count with us. And we were
a CDC or HHS officers—public health

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able to fulfill that having presence, [a] Because once [the SJ VAMC ICC] started to
physical presence, with them in the differ- receive so many requests from the commu-
ent meetings since day number one. (DT2) nity, [the incident management team] real-
ized it was better that they know. We had
Involvement by VHA in the local coordination meetings—let’s say every other hour . . . so
of healthcare response created opportunities for VA they [other agencies or other kind of sup-
CHCS to provide support to local healthcare agen- port] could come if there was any requests.
cies. As described by one respondent, during the (DT2)
first few days after Hurricane Maria made landfall,
multiple local hospitals turned to the VAMC when Due to communication and transportation chal-
they struggled to get support from local government lenges, the majority of entreaties came from in-person
entities: representatives, although there was a phone confer-
ence line made available to community institutions:
And the reason why [SJ VAMC received
so many requests] is because out of many After the catastrophic event—you know,
of the medical centers, island-wide, that and after you look at yourself, that you
recovered from Hurricane Maria damage, survived, and you look at whoever is next
the VA was, I believe, probably the first one to you, you are trying to recover as fast as
that was really able to continue their oper- you can. So you are going to start probably
ations. . . . So many of the medical centers either knowing what type of supplies you
around us that were significantly dam- have, how your facility is, and then if you
aged, they were asking the [Puerto Rico] need any help, you’re going to start asking
Department of Health and other agencies, for help . . . we had no communication lines
and as they received a “no” for the answer, at all, all the companies and providers, all
they looked for VA as one of the potential their antennas were either out of power or
sources of support in that critical time. So on the ground. We had no power, no water,
we received different types of requests and no transportation—public transportation
others later on were being managed by available . . . So the only probably way, if
the [Puerto Rico] Department of Health as you have half a gasoline tank in your car,
they recovered, and of course as per HHS is to get to your car and go to your next
and the declaration of Stafford Act went in medical center that probably they are oper-
effect and we had more help from the main- ating, asking for help. And that happened
land to arrive to Puerto Rico to support the to many of the medical centers here, before
medical centers and establish back to the they came to the VA. (DT1)
normal operations months after. (DT1)
A variety of healthcare facilities turned to the
Similar to managing resource allocation to federal VA and their requested varied. Examples of services
partners, the ICC also monitored external requests to provided to the community included supplying 5,000
ensure the demands were balanced with the needs of gallons of water to support a hospital’s medication
the VA itself. The VA needed to make strategic deci- management as a stop-gap until the state could step
sions regarding resource allocation to balance person- in, delivering medication to hospitals with insufficient
nel and supplies needed for veteran patients, duties pharmaceutical supplies, providing sterilization ser-
to support federal partners, and help to the local com- vices and clean linens to facilities that did not have
munity. As one respondent described, the ICC had to the ability to conduct sterilization or maintain inter-
find a strategy to manage the influx: nal laundry services, and sending out technicians to

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support facilities with damaged air conditioners and with the VA Canteen Service, the VA found a way to
generators. ameliorate the need for accessible food purchases by
patients’ families, employees, and employees’ families
Respondents noted the VA also fulfilled a variety and neighbors. As described by a respondent:
of liaison roles. Once VA was included in the official
Puerto Rico Post ad Joint Field Office, a representa- The ATM machines were not function-
tive from OEM served as a VA liaison which greatly ing. The banks were not functioning. So
facilitated communication and resource requests. An I said to [VA Central Office], if for any
SJ VAMC representative served as a liaison to the reason we could decrease a little bit the
Federal Emergency Management Agency’s (FEMA’s) price of the food in the canteen, that was
Social Work and Mass Care Committee, establishing a the only place to eat at that moment, and
link to community agencies. Volunteer organizations [they] went above and beyond, I would say.
such as the Red Cross and Salvation Army connected Because they—not just only decreased the
directly with the SJ VAMC to describe aid they could price of the food, but they offered me to
offer to veterans and community members, allow- have breakfast and lunch at a three-dollar
ing VA to identify which organization could best fill fixed price and for dinner, each employee
community requests outside of the VA’s purview, eg, was able to take up to eight free meals to
non-veteran requests for shelter and supplies. The SJ take with them, in order that they can feed
VAMC also provided tables in their lobby for FEMA, their families. So you could imagine that
Red Cross, and Salvation Army to provide informa- the workers—at this moment, they contin-
tion and services. ued talking highly about this initiative.
We were doing that for probably five to six
An unexpected liaison role of the VA evolved months. So we are very grateful of that sup-
quickly in the first few days after the hurricane port from National VCS—Canteen Service.
through the VA call center. The communication chal- (DT2)
lenges between the island of Puerto Rico and the
mainland of the United States restricted families With the extensive resources available from the
being able to connect in the post-hurricane period. greater VA, VA CHCS was fortunate that it did not
The call center set up by the VA to assist in schedul- need to rely on assistance from the community to sup-
ing appointments evolved into a communication hub, port medical continuity of operations; however, they
where family members of veterans from the con- did rely on relief agencies based on the island for a
tiguous states would call asking whether the VA had variety of other needs. As described by a respondent,
information about their family members in Puerto once veterans were discharged from the hospital,
Rico. Such calls were passed to SJ VAMC, which there were areas of support patients and their fami-
would send a crew of social workers equipped with lies needed that were traditionally outside the scope
satellite phones to the veteran’s home so they could of VA services. The VA connected veterans and their
connect veterans with their family members in the families to social service and disaster relief organiza-
states. tions to meet these needs:

In the wake of the hurricane, there was not only . . . we were not able to discharge patients,
limited potable water but also limited access to cash or even though we had every day, 40 to 50
places to purchase food. SJ VAMC had pallets of water patients with orders to be discharged, we
and meals ready to eat, which had been supplied could not discharge them because a lot of
by FEMA and VHA, available to distribute. These veterans lost their houses. Maybe they had
services and supplies were made available not only family, they didn’t have food, they didn’t
to veteran patients, their families, and VA employ-
ees but also to any community member who walked
into the facility. Additionally, through a partnership

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have clothing. So if I didn’t divert them to coordination and its ability to directly liaise with
the [VA established] shelters, I was not able partners. Subsequently, respondents noted that the
to admit more veterans to the inpatient and efforts of the VA following the hurricane helped its
the ER was completely packed. And it hap- move from being viewed as a disconnected, “federal
pened in all disciplines. Medicine, surgery, entity” to one of the “community hospitals,” while
and mental health. So we used the [VA also demonstrating the value it could bring to Puerto
established] shelters as that swing space Rico’s healthcare infrastructure. As described by one
while we were addressing the social issues respondent:
with local agencies and with their families.
We didn’t want any veterans to get out of What we have gained from that relation
the hospital and they didn’t have a good and those exercises is that for example now,
place to live or that they didn’t have food there is a lot of effort for future prepara-
or clothing. (DT2) tion last year and this year. We have been
a part of all the planning sessions, all the
Other examples of relying on aid agencies included different response drills and everything,
helping VAMC staff reach patients in areas that so my Emergency Management Team here
required special transportation, and when conduct- has been instrumental, because they are
ing wellness checks with “special diagnoses patients,” invited and now we are another compo-
eg, patient with spinal cord injuries, chronically ill nent of all that massive effort in the state
patients, patients on dialysis, etc., coordinating with here in Puerto Rico. So they see now us as
different agencies to help support issues outside of another center—and actually, they identi-
the VA’s scope. fied us as a best practice. Because this was
not the reality of the rest of the hospitals in
Lessons learned Puerto Rico. They suffered a lot because of
The timing of the interviews, one and a half years the infrastructure in Puerto Rico, but being
a Federal agency, having all the support
post-hurricane, allowed respondents a chance to that we had through the Federal venue
reflect on key lessons learned. The first was that the [we could be a best practice due to our
geographic challenge of Puerto Rico not being contigu- resources]. (DT2)
ous to the United States translated to all necessary
resources needing to be shipped or flown in after a DISCUSSION
disaster. In order to ameliorate this, respondents indi-
cated an increase in the prepositioning of resources on The 2017 Atlantic Hurricane season was one of the
the island following Hurricane Maria. Respondents worst on record, with the island of Puerto Rico experi-
indicated a new mobile medical unit and an increase encing near total devastation by Hurricane Maria.10,16
in stockpiled water and gas that were purchased and Lack of food, water, and power resulted in serious
stored at SJ VAMC to reduce wait time and logistical health consequences and significantly impacted criti-
challenges of getting these resources to the island in cal infrastructure such as hospitals, where reliance on
the case of another disaster event. generator power curtailed their capabilities.9 There
is a growing body of research showing the potential
Respondents also discussed the evolution of emer- for similarly destructive seasons in the future.17,18 To
gency management relationships in Puerto Rico since protect communities from the devastating impacts of
Hurricane Maria. Prior to Hurricane Maria, even future disasters, building community resilience prior
with efforts by VA to establish relationships in the to an incident is a key, and one way to do so is through
community, there was a perception that the SJ collaboration across sectors and between public and
VAMC was “apart” from the rest of the hospitals private organizations.
on the island. This delayed VA’s inclusion in local

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Community resilience is made up of many well- Disaster planning and building healthcare coali-
documented factors.18,19 Healthcare coalitions rep- tions rely on the development of relationships and an
resent one key facet of that concept because com- understanding of the types of resources local agencies
munities, and their healthcare systems in particular, can bring to bear in the time of crisis.4,19 Although
cannot efficiently recover from disasters when work- the most recent structure of healthcare coalitions in
ing within a siloed approach.2,18 The evolution of the United States centers around nongovernmental
healthcare coalitions as a multiagency collaborative agencies, there is a robust history of public–private
strategy for disaster response has been detailed in the partnerships,5 and, this case study would suggest
literature4,5,19-21; however, publications often reflect that to maximize community resilience, it is neces-
the exclusive experiences of community, nonfederal sary to include federal governmental entities when
partners. considering community resources.18,19 This case study
profiling the VA CHCS’s efforts after Hurricane Maria
The VHA, by virtue of its presence in virtually demonstrates that VA CHCS was not only able to con-
every community of the United States, has a unique tinue providing services to its patients but, with sup-
opportunity to support the community following port from the larger VA system, also able oftentimes
almost any disaster in the nation. Yet VA emergency to assist the local community with a wide variety of
managers can face a variety of challenges to engaging resource gaps. The resources of the larger VA system
in community preparedness,6 and the potential oppor- enhanced VA CHCS’s ability to continue internal
tunities for VA to operate as a healthcare coalition operations and fulfill its role as a federal partner. The
partner are often nebulous to the greater emergency advantages of being part of a larger system and hav-
management community. This study extends the lit- ing access to its resources would likely apply to other
erature about the benefits of collaborative disaster large, integrated health systems and could similarly
response by examining VA’s role supporting local suggest that such systems may also be able to pro-
healthcare infrastructure. The case study also demon- vide support to the local community. In addition, it is
strates the multifaceted roles that large hospitals and important to note that confidence in the SJ VAMC’s
health systems can play in disaster response. ability to maintain its own internal operations was a
large part of why the VA CHCS Incident Management
Although VA medical facilities are restricted by Team believed it was also able to address many exter-
their primary mission to serve Veterans and their nal needs.
families, this study shows that during catastrophic
times, the Fourth Mission is often enacted, extending Healthcare employees’ availability is essential
support to the larger community. Similarly, the recent to maintaining continuity of operations after a dis-
pandemic outbreak of COVID-19 has led to an unprec- aster.23 Staff can be just as impacted by the event
edented strain on healthcare infrastructure and led to as the patients they serve. Accordingly, VA CHCS
the activation of VAMCs across the nation to provide took steps to support staff through various creative
healthcare to non-veteran patients. Across the United avenues, including providing laundry services to
States, the VA has supported the national response to reduce the need for limited clean water resources.
COVID-19 by dedicating acute and noncritical hospi- Additionally, the Incident Management Team made
tal beds to the treatment of non-veterans, providing an active decision support not only its workforce
supportive care to non-VA nursing home patients, but also family and friends of employees where pos-
and deploying mobile pharmacy and clinical support sible. They provided reduced cost meals to staff, and
to community sites.22 The experience in Puerto Rico then began offering eight free meals for staff to take
provides a specific example of the ways a VA facility home for almost half a year after Hurricane Maria.
can contribute to a local community response both in Through this initiative, VA CHCS leadership was able
terms of health services and in a broader capacity, to deepen and extend their support to their employees
demonstrating the importance of including VA facili- as well as their employees’ direct communities. These
ties in local healthcare coalition planning.

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types of intentional activities serve as exemplars, VA to play a liaison role in several ways, including
both in the way an institution can be flexible and connecting veterans and community members to
innovative in the types of support it provides and of volunteer organizations providing aid and acting as
how a coalition can tap into available institutional a go-between for family members in the continental
resources to strengthen its adaptive capacity to serve United States to track down missing family members.
the community after a disaster. It is through this series of extensive and varied efforts
to integrate into the local coalition’s response that VA
Part of a community’s ability to successfully CHCS has now become actively engaged with helping
recover from disaster is its ability to tap into and Puerto Rico prepare itself for future events.
equitably distribute federal resources.19 Study
respondents described how VA fulfilled traditional LIMITATIONS
HHS requests, such as providing inpatient care for
non-veteran dialysis patients and space to base field This study has limitations. The interviews took
operations. It also went beyond traditional expecta- place 1.5 years after Hurricane Maria, presenting
tions by adapting to identified needs and providing a possibility that interviewees may have trouble
physical space for federal agencies to provide care in remembering accurately. However, multiple inter-
more rural parts of the island through their outpa- viewees were able to corroborate the same informa-
tient clinics located throughout the island. This was tion. Puerto Rico’s status outside of the continental
particularly important as regions disproportionally US resulted in logistical challenges to receiving exter-
affected by Hurricane Maria tended to be poorer or nal resources. Physical isolation from neighboring
more rural.24 Colocating federal partners at rural communities and damaged infrastructure increased
clinics to provide services to the community helped the island’s reliance on existing resources already
ameliorate some of Maria’s impact in Puerto Rico’s prepositioned locally until outside assistance was
more isolated regions. Finding ways to improve the accessible. This study focused on the experiences of
disaster resilience of economically depressed or iso- VA employees fulfilling mission requirements and
lated areas is a vital part of improving overall com- their description of instances where the VA acted in
munity resilience.24,25 support of the Fourth Mission. Neither community
members nor coalition partners were interviewed.
Colocating and sharing resources requires coor- Non-VA participants may have offered differing or
dination, yet, lack of coordination in disaster relief additional perspectives.
efforts is often a barrier to an effective disaster
response.26 This study found that one of the first steps CONCLUSION
the VA took to diminish this potential outcome was to
establish a presence in the local hospital coordination As one of the largest healthcare institutions in
effort to prevent itself from being siloed. Furthermore, Puerto Rico still functioning immediately after the
they worked with federal, local, and nongovernmental impact of Hurricane Maria, the VA CHCS played an
agencies to coordinate access to available resources. important role in supporting Puerto Rico’s healthcare
Hospital requests for emergent needs like water and infrastructure. A large part of this success stemmed
sanitation services were prioritized based on resource from being a part of the VHA, which provided prehur-
availability and balanced with internal needs. As ricane investment via dedicated preparedness fund-
noted, VA CHCS was able to fulfill a wide variety of ing leading to extensive prepositioning of emergency
local healthcare institutions’ requests, in turn allow- resources. The larger VA system additionally provided
ing those facilities to continue their own operations. immediate access to emergency response support from
Additionally, by the virtue of making itself available the national OEM. Notwithstanding the requirement to
to community partners, VA CHCS Incident Command support other federal partners, resources and activities
developed a depth of knowledge of existing community- could have been directed exclusively to maintaining
based resources. This cross-communication allowed internal continuity of operations. However, VA and VA

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