Journal of Emergency Management

range of derivative products would reach a wide cross time-sensitive hazards information for Puerto Rico in
section of the Puerto Rican population. Spanish related to both earthquakes and hurricanes.

The process of creating the Landslide Guide as PRINCIPLES OF COLLABORATIVE RISK COMMUNICATION
well as these derivative products is shown in Figure 3.
This roadmap is meant to illustrate the major mile- The following core principles informed this col-
stones along the way and the key partnerships that laborative project and the process described above:
made this effort possible. cultural competence, ethical engagement, listening,
inclusive decision making, empathy, convergence
The time and effort dedicated to the Landslide research, nested mentoring, adaptability, and reci-
Guide and derivative products have paid off in terms procity (Table 1). Together, these principles help
of expanding the projects’ reach. For example, 500 illuminate how to engage in collaborative risk com-
people have attended our presentations, and, col- munication while harnessing the power of interdisci-
lectively, there have been more than 18,000 views of plinary, cross-cultural teams. It is important to under-
our recorded video presentations and interviews on score that these principles all operate simultaneously
social media. We have also received a dozen requests and reinforce one another throughout the risk com-
from stakeholders for presentations about landslides. munication process. They help address questions of
To date, 700 print copies of the guides have been dis- how to build and sustain the successful relationships
tributed to residents by our team or through our risk that enable multidirectional exchanges involved in
communication partner organizations. Posts on social collaborative risk communication.
media about the Landslide Guide have received thou-
sands of likes, comments, or shares, and commenters Cultural competence
often thank us specifically for providing this informa- Cultural competence is one of nine core princi-
tion in Spanish. Indeed, our extended network of risk
communicators has helped the USGS communicate ples that we used to guide our efforts in Puerto Rico.

Figure 3.  Roadmap illustration of the process used to develop the Landslide Guide, starting on the left. Circles
with arrows represent iteration of activities.

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Table 1. Principles of collaborative Disaster researchers and emergency manage-
risk communication ment practitioners commonly work in geographic and
cultural contexts that are unfamiliar to them, so cul-
Cultural Aligning the project with social, cultural, tural competence is critical for outside professionals
c­ ompetence historical, political, and environmental to ensure their actions do not exacerbate inequality or
contexts to provide greatest benefit further harm affected populations.40,45 Because four
of the seven members of our core team do not live in
Ethical Building collaborative working Puerto Rico, cultural competence was important for
engagement relationships based on what is just, aligning our perspectives and communication with
equitable, and morally sound for all the local cultural context. Three of the non-Puerto
involved Rican members of our team are proficient in Spanish,
and each person made a concerted effort to under-
Listening Seeking regular feedback in recognition stand the unique culture and environment of Puerto
of the knowledge and capacities of local Rico by immersing ourselves in Puerto Rican media,
populations reading books by local authors, listening to podcasts,
and visiting cultural and historical sites during time
Inclusive Encouraging and utilizing input from spent on the island.
decision making all those who come into contact
with the project, including creating a As indicated previously, one of our policies was
nonhierarchical team structure to develop the education and outreach materials
in Puerto Rican Spanish first, then to translate to
Empathy Recognizing, respecting, and validating English as needed. This stands in sharp contrast to
the unique experiences of people traditional science communication practice on the
involved with or affected by the project US mainland, where most of the guidance about
hazards is written or created in English first, then
Convergence Approaching research through the lens (sometimes) translated to other languages. Most of
research of a specific and compelling problem and the population in Puerto Rico speaks Spanish as their
working toward solutions that require primary language, so creating content in Puerto Rican
extensive integration across disciplines Spanish at the outset was an important aspect of our
risk communication efforts. This approach ensured
Nested Mentoring of current and next- our educational materials would be as relevant and
mentoring generation professionals through intuitive as possible to our intended audience.
reciprocal relationships
Collaborative efforts among professionals and
Adaptability Anticipating and making changes as students in Puerto Rico and with the external
needed in response to new information stakeholders helped accelerate what Wu et al.40
and current events have described as a stepwise process for developing
cultural competence, where researchers and practi-
Reciprocity Finding meaningful, tangible ways to give tioners move from cultural awareness, to knowledge,
back to those who contribute to a project to sensitivity, to competence. Strong rapport among
through a practice rooted in gratitude team members supported regular, open communi-
cation that guided the project towards alignment
Cross et al.44p13 define cultural competence generally with the local cultural context. These relationships
as: “A set of congruent behaviors, attitudes, and poli- provided avenues for direct and immediate feedback
cies that come together in a system, agency, or among about adjustments that needed to be made to the
professionals and enable that system, agency, or those education and outreach materials and the process
professionals to work effectively in cross-cultural used to develop them.
situations.” With respect to collaborative risk commu-
nication, we define cultural competence as the proac-
tive and ongoing process of aligning our project with
social, cultural, historical, political, and environmen-
tal contexts to make the risk communication process
and products relevant, appropriate, and beneficial to
those exposed to landslide hazards.

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Ethical engagement types of questions about our work, our goal was to
Research ethics is a broad term that refers to infuse ethical decision making throughout our entire
engagement process and to make the most ethically
a set of principles, or ethical standards, that gov- informed decisions possible.36
ern the conduct of scientific research and practice
and, above all else, “protect the dignity, rights, and Ethical engagement is critical across the disaster
welfare” of those involved.46 Recent publications lifecycle—from preparedness to response to recovery
have called for greater attention to ethics in disas- to mitigation. During postdisaster periods in particu-
ter research.47,48 Browne and Peek36p82 observe that lar, however, centering ethics becomes paramount as
ethical concerns span the entire lifecycle of long-term researchers and practitioners may be regularly inter-
disaster research projects. Likewise, risk communica- acting with disaster-affected people who are coping
tion projects often involve ethical uncertainties and with varying forms of trauma and loss.47 We were
asymmetrical relationships among participants, who made keenly aware of this dynamic in Puerto Rico,
vary in their levels of influence over risk, access to as our collaborators and project participants not only
risk information, and initiation of risk communica- expressed challenges related to the ongoing impacts
tion messaging.49 Such asymmetries in risk com- of Hurricane María but also described the economic
munication create the potential for ethical dilemmas inequality, social disinvestment, and chronic hazards
that can threaten to upend research projects and such as heat and flooding that made recovery slower
practical interventions.36 and more difficult. While we could not address every
issue, centering ethics helped us to see through a
In response to the complexity of engaging ethi- more holistic and principled set of lenses.
cally in diverse communities, the field of risk com-
munication has moved toward centering core princi- Listening
ples of risk communication while adapting them to The principle of listening was central to this pro-
ensure that audiences and stakeholders from across
the whole community are involved. This entails ask- ject. Collaborative risk communication calls for listen-
ing about “political, ethical, and other issues that ing to local stakeholders from the start and develop-
may shape people’s attitudes toward risk and their ing the project from the ideas and feedback shared.
capacity to take steps to reduce it.”17p11 Thus, the Our commitment to listening emerged both from our
principle of ethical engagement in risk communica- commitment to the practice and from prior caution-
tion seeks to proactively acknowledge and address ary tales. Indeed, in a variety of postdisaster contexts,
imbalances among collaborators and participants in problems have arisen when outsiders did not take
a risk communication process while moving toward the time to listen to local people.50 Thus, listening to
more just and equitable approaches to community the stories of local people and fellow collaborators is
involvement. essential to ensuring that interventions are effective
and appropriate for the local context.51,52 Listening
We sought to use ethical engagement as the first focuses on ensuring that every individual involved
and final reference points for any major decisions in in the project is heard so that their contributions can
our project. At a minimum, ethical boards and other help shape and advance the project’s mission.
institutional oversights require researchers to “do
no harm.” By centering ethics in our practice, our In collaborative risk communication, listening
team sought to move beyond such basic institutional provides a mechanism for multidirectional commu-
review board requirements. This meant, in practice, nication and an understanding that all perspectives
that we regularly asked questions like, Is this ethi- are valued. In essence, listening can help counter-
cal? Ethical for whom? Is this just and fair? How can act power imbalances and the tendency of one-way
we ensure that our own ethical principles and the risk communication that privileges scientific over
values of others are inherent in the processes and local knowledge. Collaborative risk communication
the products that we are creating? By asking these involves taking the time to identify, meet with, and

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hear local voices, and then adapt the project to reflect incorporating input from all stakeholders. This
their requests and contributions. It prioritizes rec- approach draws upon definitions of inclusive risk
ognizing the knowledge and experiences of others. governance53 as well as participatory research
Listening as a principle also means asking questions approaches,54 which recognize an expansive range of
and being prepared to receive critical and construc- knowledge types and encourage reflexivity in deci-
tive feedback to help enhance project deliverables. sion-making processes. In this project, the principle
of inclusive decision making involved encouraging
Seeking out and working to understand the per- constructive feedback and responding to input from
spectives of local risk communication professionals, all those who became involved. While we sometimes
urban planners, emergency managers, and residents received conflicting feedback—and, therefore, could
was a critical part of crafting the Landslide Guide. not follow every recommendation—we remained com-
By starting the project with months of informal inter- mitted to inclusive decision making and thoughtful
views, meetings, and focus groups, we created oppor- action at all times.
tunities to listen and gathered key perspectives that
informed the concept for the guide. Conversations Inclusive decision making, like listening, relies
with professionals and residents throughout Puerto on demonstrating respect for each person’s knowl-
Rico helped define a list of desirable characteristics edge, experience, and perspective, regardless of any
for the guide and associated materials. For example, social or professional status. In terms of the dynamics
we heard from stakeholders that the guide needed within our core team, each member had varying lev-
to be scientifically accurate and culturally relevant els of experience and was at a different career stage.
to Puerto Rico. We learned that it needed to be Nevertheless, each team member’s ideas were treated
cocreated, endorsed, and used by a wide variety of as equally valid and were incorporated when feasible
stakeholders throughout the island. into project-related decisions. As a matter of practice,
none of our senior members made a decision without
Our team originally considered creating two sepa- consulting other members of the core team and local
rate guides about landslides, one for residents and one stakeholders in Puerto Rico.
for emergency management professionals. However,
listening to emergency managers, planners, scientists, When a decision needed to be made, our core team
and other stakeholders, made evident that a sin- did so through a bottom-up process of consensus, consol-
gle guide could serve the needs of both audiences. idating the input from our extended network. Because
Residents could learn directly from the pages of a local team members in Puerto Rico had the best context
guide, while hazards professionals could use it as a for what decision would be appropriate regarding many
tool for dialogue to engage community stakehold- issues, it made sense for our Puerto Rico-based team
ers and exchange knowledge. Emergency managers members to lead the consensus-based decision-making
indicated that they could use the guide as a reference process. Reaching consensus involved combining differ-
and starting point for reaching different audiences, ent types of expertise, including: the lived experience
combining its recommendations with their knowledge and situational awareness of undergraduate research
of Puerto Rico and emergency management. Through assistants in Puerto Rico; field research and scientific
this process of listening and tailoring our products expertise on landslide hazards; and the decades of
to local needs, we demonstrated respect for local experience of senior team members related to risk com-
knowledge and experience. As a result of these efforts, munication and project management.
several stakeholders have incorporated the guide and
related products into their ongoing outreach activities. Because of the hierarchical systems that struc-
ture our work environments in academia and gov-
Inclusive decision making ernment, the principle of inclusive decision making
Inclusive decision making refers to the demo- needed to be reinforced regularly throughout the
project to ensure all team members felt confident and
cratic process of steering a project by proactively welcome to voice their ideas and concerns. Any time

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we faced major turning points in the project activi- of collaborators. We recognized that many of these
ties, our options for next steps were generated among professionals work tirelessly to decrease risks to the
the whole team, including input from colleagues in people they serve. Some of our collaborators included,
our extended network; then, next steps were decided for example, a local emergency manager who is called
upon as a collective. The principle of inclusive decision when landslides block roads and access to hospitals;
making established a flat structure, rather than a planning officials responsible for advising on the
top–down hierarchy, in terms of how the team worked geology of zoning; weather forecasters entrusted with
together and steered the project. providing timely and life-saving information to the
public; and university professors, who were often jug-
Empathy gling teaching courses and research with responding
Empathy is a cornerstone of our model of collabo- to the needs of their students and local communities.
Each of these partners had different responsibilities
rative risk communication and, recently, it has been and demands on their time, but they all shared a com-
recognized as a key component of other models of risk mon desire and sense of responsibility for the well-
communication.8,55 We define the principle of empathy being of others. Meanwhile, these professionals were
as recognizing, respecting, and validating the unique often dealing with the cascading effects of compound
experiences of people involved with or affected by the natural hazards and disaster fatigue in their own
project. These stakeholders include those with whom lives and households.
we communicate about risk, those with whom we col-
laborate, and members of our core project team. As our recognition of struggles and strengths
improved, empathy was a core operating principle
Empathy helps risk communicators meet people for our efforts. Our team is composed of people of
where they are. In the Crisis and Emergency Risk various ages, ethnicities, gender identities, geo-
Communication (CERC) model, for example, empathy graphic locations, career stages, disciplines, and
is not just a means to improve risk communication, it personal experiences with disasters. Our team mem-
is an end goal associated with providing reassurance bers in Puerto Rico are both hazards professionals
and reducing emotional turmoil.8 Though empathy as well as survivors of multiple disasters, including
is not included in all stages of the CERC model, we Hurricane María. In order for everyone to work
argue that empathy can improve the entire risk com- collaboratively, empathy was a necessary practice.
munication cycle. It enabled us to foster mutual respect among a
loosely networked group of people from different
As we developed landslide risk communication backgrounds. Empathy also guided our response
materials, our project team recognized that empathy to unexpected situations and compounding disas-
was crucial to understanding the type of information ters that arose in the course of our work together,
we ought to provide. As members of our project team including the 2020 Puerto Rico M6.4 earthquake
interfaced directly with residents whose homes were and associated seismic sequence, chronic flooding
cracking because they were situated on active land- across Puerto Rico, and the global COVID-19 pan-
slides, the problem we were tackling was no longer demic that affected us all.56 Empathy took the form
abstract—it was personal. Many of the people who we of checking in with team members and collaborators
met were still living in their homes despite the possi- on a personal level and creating space for those con-
bility of catastrophic failure of nearby landslides, and cerns to take precedence over our work together or
those who had been directly affected by landslides any competing deadlines. More generally, empathy
expressed a sense of loss, anxiety, and frustration. A provided a strong motivation to participate in col-
strong sense of empathy for these emotions motivated laborative risk communication and established a
our team to do as much as possible to respond to foundation to navigate complex circumstances while
expressed needs and desires. cocreating with diverse teams and networks.

Building and practicing empathy facilitated
stronger working relationships within our network

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Convergence research we did to address them. This meant, in practice, that
Hazards researchers and practitioners have long each time that we identified a driver of landslide risk,
we would ask what could be done about the problem—
recognized that rising disaster losses demand new from the perspective of emergency management, aca-
approaches to risk reduction. Convergence, with demic research, or mitigation practice. This problem-
its focus on deep integration across disciplines and focus and solutions-orientation helped us to develop
research driven by a specific and compelling problem more realistic approaches for potentially responding
and the potential for novel solutions, offers one such to the myriad challenges we had identified.
possibility.57 In their effort to bring a convergence
framework to the hazards and disaster field, Peek Nested mentoring
et al.10p1 define convergence research as: “An approach Nested mentoring is a practice in which project
to knowledge production and action that involves
diverse teams working together in novel ways—tran- team members learn from one another’s personal and
scending disciplinary and organizational bounda- professional experiences to support the learning and
ries—to address vexing social, economic, environmen- development of each team member and improve col-
tal, and technical challenges in an effort to reduce laboration that is necessary for convergence (also see
disaster losses and promote collective well-being.” Bronner et al.58). It shapes the structure of a team by
Our core team was poised from the start to adopt a embedding multiple layers of mentoring relationships
convergence-oriented approach to our efforts. Our within it, such that early career team members have
team and extended network of collaborators included opportunities to learn from more experienced team
a broad range of disciplinary backgrounds relevant to members, and vice versa. Nested mentoring facili-
landslide hazards, including geology, sociology, urban tates a multidirectional exchange of knowledge and
planning, emergency management, and meteorology. experience, which also aligns with best practices for
We also worked across organizational and geographic risk communication.
boundaries.
Among our core team, these nested mentoring
What bound us together in this project was our relationships typically consisted of students and
common focus on the specific and compelling challenge other early career team members learning from more
of landslide risk in Puerto Rico and our commitment experienced team members. Still, everyone recognized
to addressing the underlying drivers of that risk. Such there was a possibility for multidirectional sharing of
“problem-driven” and “solutions-based” approaches knowledge, information, and experience that under-
are a hallmark of convergence research, which often pinned the growth of individuals and the team as a
requires new processes for encouraging deep discipli- whole. These relationships helped honor the different
nary integration, communication, and collaboration.10 types of expertise that each team member brought to
For our team, this entailed aligning and integrating the project. Structuring our work this way ensured
our different languages (Spanish and English), sci- that one outcome of the project, in addition to produc-
entific vocabularies (geoscience, social science, urban ing landslide materials, would be training the next
planning), networks (government, academic, private generation of disaster researchers and practitioners.
sector, nonprofit, and media), and understandings of It also enhanced the mentoring capabilities of all
risk. Our common commitment to one another and team members.
to the process of convergence to address vexing chal-
lenges bound us together and drove us to overcome We used nested mentoring to support and ele-
disciplinary and organizational divides. vate the voices of the early career members of our
team. For instance, after learning from and practicing
In addition, adopting a convergence mindset with more senior team members, the undergradu-
meant that our team focused on the root causes of ate research assistants presented this work at their
landslide-related losses as well as potential solutions. first scientific conferences as well as at meetings that
We worked as diligently to characterize challenges as centered the voices of students involved in research

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after Hurricane María. Nested mentoring helped team directly on the federal and local government response
members understand how this project contributed to to the unfolding seismic sequence. The earthquakes
each individual’s future goals. For example, we chose also triggered landslides in the form of rockfalls, one
activities that would provide the undergraduate and of which briefly blocked a highway connecting south-
graduate student team members with experiences west Puerto Rico to the capital city San Juan, where
that could support their application to graduate pro- many residents commute for work and other needs.
grams or internships in their fields, and we ensured There was a renewed sense of urgency and demand
that more senior team members were able to complete for landslide hazard education and outreach materials
and submit required project deliverables on time. amid the earthquakes, and we recognized the need to
act quickly. We accelerated the public release of the
Nested mentoring supported successful internal Landslide Guide to make it available to residents and
processes that advanced our external collaborative emergency managers in Puerto Rico as of February
risk communication efforts. By aligning project-based 2020. We were able to adjust our timeline because we
efforts with the individual goals of each team mem- had created a Communication and Outreach Plan well
ber, we were able to generate a wider suite of prod- in advance of our anticipated launch date. In it we
ucts than we had initially envisioned. By showing a had already identified our relevant audiences and the
common commitment to one another, we were able channels for distributing the Landslide Guide.
to sustain motivation and enhance team member
satisfaction as we simultaneously built more robust As the earthquakes continued and our team
partnerships with one another as well as across the planned events in Puerto Rico, COVID-19 brought
network we were developing. most travel to a halt. Puerto Rico mobilized in March
of 2020 to stop the spread of COVID-19 with strict
Adaptability curfews and public health communication campaigns.
Adaptability in collaborative risk communication For our project, limitations on in-person risk commu-
nication activities forced us to reimagine the distri-
reflects the ability and forethought necessary to work bution of the landslide materials to prioritize digital
with a dynamic set of circumstances that might alter formats for the foreseeable future. We sought out and
the trajectory of the project. Research on community established new partnerships for online risk commu-
engagement for disaster management has empha- nication about landslides. For example, our Puerto
sized the need for flexible and adaptable approaches,59 Rico-based team members initiated a new partner-
recognizing that rigidity decreases the ability to crea- ship with the local science museum. This and other
tively overcome obstacles to project implementation. such ongoing and emergent partnerships allowed us
Working in Puerto Rico over the course of three years, to connect with our extended network to verify how
we found our project affected by additional natural each of their organizations was adapting to conditions
hazards, political turnover, and ongoing economic cri- amid the pandemic and to learn how they wanted to
ses. Our team had to be prepared to adapt as needed receive the coproduced landslide materials.
to both new information and to these current events.
The structure of our team enabled the flexibility and Reciprocity
adaptability that this project required. The principle of reciprocity encourages a mutual

The principle of adaptability proved particularly exchange and benefits for all participants involved
important immediately before the planned launch of the in research or a collaborative process.62 We under-
Landslide Guide in early 2020. The Southwest Puerto stand reciprocity to involve maintaining relation-
Rico Earthquake Sequence started in late December ships and finding tangible ways to give back to those
2019 and included the M6.4 mainshock on January who contribute to the project. Giving back can be
7, 2020. The mainshock and associated earthquakes accomplished through a variety of mechanisms over
damaged many homes and buildings in the southwest time, for example, by offering verbal expressions of
part of the island.60,61 Members of our team worked

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thanks, volunteering to assist collaborators with their by ethical principles for the coproduction of natural
projects, giving gifts, providing food, or compensating hazards knowledge and communication products by
people for their time. local and external stakeholders. Collaborative risk
communication is characterized by a cyclical process
Expressing gratitude is one important form of of collaboration, cocreation, and feedback on risk com-
reciprocity. Given the importance of gratitude, we munication materials and activities over time. This
embedded this practice in all our team’s interac- approach builds upon numerous existing frameworks
tions. Opening meetings with expressions of gratitude for risk communication6-9 with an eye toward the
came to define our project culture and these actions increasing need for convergence research in the face
shaped our work together as a team. We found that of compound hazards and disasters.10
actively valuing individual contributions helps foster
a positive atmosphere that motivates hard work and Disaster management stakeholders and practi-
preserves the momentum of education and outreach tioners often represent a wide range of disciplines,
efforts. Molding the project into a vehicle to elevate from physical science and sociology to engineering
local voices on hazards and risk communication, and planning. Collaborative risk communication ena-
particularly those of our student team members and bles such diverse and often geographically distributed
volunteer collaborators, had the added benefit of stakeholders to work together to align understand-
empowering and increasing the cohesiveness of our ings of risk and cocreate relevant communication
core team and extended network. products. Accessible risk communication products
are a necessary foundation for informing protective
In addition to expressing gratitude, we also had behavior and reducing losses among people exposed to
project-related funds to support many activities. This landslides.63 Stakeholders become engaged in a long-
meant that we were in a position to, for example, term dialogue that enhances understanding of risks
purchase food for in-person meetings, reimburse as well as options to manage them.64
travel expenses for project partners, and compensate
our research assistants for their efforts. Although This article demonstrated how we enacted collab-
our team did not have limitless resources, we tried orative risk communication in a project we launched
to channel those that we did have toward our stake- following Hurricane María and which resulted in
holders in ways that aligned with their requests and the publication of the Landslide Guide for Residents
needs that we observed. of Puerto Rico. Specifically, we detailed the process
used by our team in Puerto Rico to develop landslide
We prioritized giving credit to the members of risk communication products and described the set
our team and network of collaborators in our project of core principles that informed our every effort both
deliverables. Similarly, we provided either a Natural internally and externally. These principles—cultural
Hazards Center affiliation or USGS Volunteer sta- competence, ethical engagement, listening, inclu-
tus to the students and early career members of our sive decision making, empathy, convergence research,
project team. A commitment to reciprocity led us to nested mentoring, adaptability, and reciprocity—were
provide all of our risk communication products for used both within our core team and in the broader
free and in many formats, including presentations, ecosystem of partnerships that we formed over the
videos, classroom lectures, TV interviews, and copies years following Hurricane María.
of the guide in print and online. We have continued to
seek out ways to complement and amplify the work of The collaborative risk communication framework
our collaborators and to ensure that their efforts are places an emphasis on sound science, principled
recognized, respected, and valued. engagement with stakeholders, and justice in disas-
ter research and practice.65,66 Puerto Rican scholars
DISCUSSION AND CONCLUSION have called attention to the archipelago’s history of
disaster colonialism, demonstrating how past- and
We began this article by defining collaborative present-day disaster policies have too often reinforced
risk communication as an iterative process guided

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

power imbalances and social inequality.67-69 Risk com- We came to recognize time as an especially impor-
munication processes and products that are developed tant dimension for further consideration in the context
from a collaborative risk communication perspective of collaborative risk communication. Different levels
can actively counter such asymmetries to reduce dis- of engagement and collaboration with counterparts
aster losses and support equitable recovery. require vastly different time commitments. On a few
occasions we realized that too much time had passed
Together, the set of principles described in this since our core team had consulted with some stake-
article offers a framework for carrying out collabora- holders, reminding us of the consistent commitment
tive risk communication projects. We take the position required to maintain strong relationships that facilitate
that these principles are integral to enacting col- collaborative risk communication. Instead of taking the
laborative risk communication, which we conceptual- approach described in this paper, it might have been
ize as an ongoing and mutually reinforcing process, possible for our core team to develop a landslide guide
rather than an end state (Figure 4). This recognition outside of Puerto Rico, and then consult with Puerto
of risk communication as a process became especially Rican stakeholders only in the final stage. While such
important as our project progressed and Puerto Rico an approach might have required less time, fewer part-
experienced multiple compound hazard events that ners, and fewer resources, it would not have resulted in
resulted in cumulative disaster exposures.70,71 As the a product that was coproduced, vetted, and ultimately
risk communication landscape grew more compli- coowned by residents and experts in Puerto Rico.
cated over time, our collaborative risk communication
framework allowed us to adjust and adapt both our Beyond the production and distribution of the
processes for engagement with partners as well as the guide, adhering to the principles that allow collabo-
products that we were developing. rative risk communication to thrive also requires an
investment of time. Therefore, for those who are inter-
Figure 4. This illustration shows the mutually rein- ested in pursuing this approach, it is important to
forcing relationships between the nine principles of recognize that slowing down and placing the process
collaborative risk communication. The principles are before the product is paramount to its success. For
not hierarchical and are therefore not intended to be this reason, collaborative risk communication efforts
ranked relative to one another. should carefully consider such time commitments in
advance and establish a realistic project timeline in
consultation with collaborators. While developing the
Landslide Guide, our team had a flexible timeline and
sufficient funding to allow the project to evolve over
the course of approximately three years. Partnering
with local counterparts can lead to vastly improved
and more usable communication products, but it calls
for allocation of sufficient numbers of people and
project resources, both financial and time-related, for
effective project planning and management. In the
long run, time invested facilitates a process that can
generate enduring networks of mutuality and reci-
procity rooted in an ethic of care and respect.72 The
collaborative risk communication process is designed
to generate benefits for those involved along the way
as well as those served by the final products.

We tried to address as many aspects of landslide
risk communication as we could with the resources

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Vol. 19, No. 8

we had; however, there are areas we have not yet Raquel Lugo Bendezú, BSc, Department of Geology, University of
addressed that we hope will receive attention by Puerto Rico—Mayagüez, Mayagüez, Puerto Rico.
researchers and practitioners in the future. For
instance, agriculture and private sector building con- Yahaira D. Álvarez Gandía, BSc, Department of Geology, University of
struction are key sectors associated with landslide Puerto Rico—Mayagüez, Mayagüez, Puerto Rico.
risk that we have not yet engaged through our project.
Reaching those who are most vulnerable will require K. Stephen Hughes, PhD, Department of Geology, University of
a continued commitment to nurturing and expanding Puerto Rico—Mayagüez, Mayagüez, Puerto Rico. ORCID: https://orcid.
the coalition of mitigation partners in Puerto Rico. org/0000-0001-9820-3188.

Although this project focused on reducing land- Jonathan Godt, PhD, US Geological Survey, Denver, Colorado. ORCID:
slide losses in Puerto Rico, the principles presented https://orcid.org/0000-0002-8737-2493.
here and the process of collaborative risk communi-
cation could be utilized across multiple geographic Lori Peek, PhD, Department of Sociology and Natural Hazards Center,
and cultural contexts. Landslide hazards were our University of Colorado Boulder, Boulder, Colorado. ORCID: https://
primary focus, but we suggest this process and the orcid.org/0000-0002-8108-6605.
principles are applicable across a range of hazard
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Appendix: Supplementary material

Contributors*

Core team Natural Hazards Center
University of Puerto Rico, Mayagüez
US Geological Survey

Collaborators EcoExploratorio
Municipal Emergency Managers
NOAA Caribbean Tsunami Warning Program
NOAA National Weather Service, San Juan Weather Forecasting Office
Puerto Rico Highway and Transportation Authority
Puerto Rico Planning Board (Junta de Planificación)
Puerto Rico Seismic Network
San Juan Puerto Rico Science, Technology & Research Trust
University of Puerto Rico, Río Piedras

Broader Network of Risk Communication American Geophysical Union (AGU)
Stakeholders Centers for Disease Control and Prevention
Federal Emergency Management Agency (FEMA)
Geological Society of America (GSA)
National Institute for Standards and Technology (NIST)
National Science Foundation INCLUDES SURGE
RISE Network and Conference
Cultural Centers
Cooperatives (eg, Cabachuelas)
Municipal Governments
News Media (eg, Noticentro por WAPA, Univision)
Puerto Rican Residents
Regional Emergency Managers

*The relative position of contributors within each of the three sections in this list does not imply a hierarchy, rank, or
­respective level of participation/contribution.

Special Issue on Puerto Rico

Journal of Emergency Management 61
Vol. 19, No. 8

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JEM Public health branch incident management and support
as part of the Federal Government response during the

emergency phase of Hurricanes Irma and Maria in
Puerto Rico and the US Virgin Islands

Miguel Angel Cruz, PhD
Luis O. Rivera-González, PhD
Elizabeth Irvin-Barnwell, PhD
Jessica Cabrera-Marquez, PhD

Esther Ellis, PhD
Brett Ellis, PhD
Benjamin Qi, PhD
Christopher Maniglier-Poulet, MS
Justin Andrew Gerding, DHA
Alice Shumate, PhD
Ashley Andujar, MHSA
Jonathan Yoder, MPH
Joseph Laco, MS
Alberto Santana, MS
Tesfaye Bayleyegn, MD
Carolina Luna-Pinto, MPH
Luis Orlando Rodriguez, MS
Joseph Roth, MPH
John Bermingham, MS
Renée H. Funk, DVM
Murad Raheem, BS

ABSTRACT organizing these activities; summarizes some key public
health activities and roles; outlines partner support and
On September 6 and 20, 2017, Hurricanes Irma coordination with key agencies; and defines best practices
and Maria made landfall as major hurricanes in the and areas for improvement in disaster future operations.
US Caribbean Territories of the Virgin Islands and
Puerto Rico with devastating effects. As part of the ini- Key words: public health, emergency manage-
tial response, a public health team (PHT) was initially ment, natural disasters, environmental health, disas-
deployed as part of the US Department of Health and ter assessments
Human Services Incident Response Coordination Team.
As a result of increased demands for additional exper- INTRODUCTION
tise and resources, a public health branch (PHB) was
established for coordinating a broad spectrum of public Major natural disasters, such as hurricanes, can
health response activities in support of the affected terri- cause widespread catastrophic damage that dev-
tories. This paper describes the conceptual framework for astates communities, threatening the wellbeing of
affected populations and their living environment.1

DOI:10.5055/jem.0631 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 63

This damage can affect critical infrastructure, includ- coordinating a jurisdictional response area is outlined
ing health care facilities (HCF), public health facilities, in the National Response Framework (NRF).4 The
and power and water systems. In addition, damage to NRF describes four fundamental response priorities:
transportation and communication systems may limit save lives, protect property, protect the environment,
access to remote and isolated communities. Disasters and provide basic human needs. Within the NRF, the
also affect vulnerable populations, such as individuals response capabilities of federal agencies are organ-
who are chronically ill or have disabilities and special ized under the Emergency Services Function (ESF)
needs, and the socioeconomically disadvantaged.2,3 construct. The Department of Health and Human
In the aftermath of any disaster, public health agen- Services (HHS) leads the response for Public Health
cies must coordinate and respond early to protect the and Medical Services activities under Emergency
health not only of affected citizens, but also of disaster Support Function #8 (ESF-8) and provides support to
responders.4 Their response supports partners in the other ESF activities such as ESF-6 Mass Care Services
affected areas several ways. They can provide remote and ESF-10 Oil and Hazardous Materials Response.4
technical consultation and assistance, support continu- This approach provides a framework for coordinating
ity of essential services, and deploy needed resources a variety of specialty teams across several agencies.
and equipment, as well as qualified individuals, to
the affected areas to augment or support response In developing this manuscript, the authors
activities. In addition, public health professionals bring reviewed hurricane preparedness and response docu-
expertise and tools to assist with evaluating and char- ments such as situation reports, incident action plans,
acterizing disaster impacts in communities.5 organizational charts, and after-action reports to sum-
marize the wide range of activities conducted by the
The portfolio of public health resources for disasters branch PHTs. This report summarizes steps taken to
includes tools and methods for collecting health surveil- establish the public health core teams and an organi-
lance data, executing risk and needs assessments, zational structure; describes federally supported public
communicating health risks, and controlling misinfor- health emergency response activities; and highlights
mation. Public health teams (PHTs) can also assist cross-agency coordination efforts to support the public
with vector control; monitor common environmental health needs of the residents in the US Caribbean ter-
hazards associated with food, water, and air contami- ritories after Hurricanes Irma and Maria.
nation; ensure safe handling of large amounts of waste
and hazardous materials; and assess health hazards in HURRICANES IRMA AND MARIA LANDFALLS AND
communities, public health and medical buildings, and
public facilities such as schools and shelters.3,6-12 Public INITIALIZATION OF PUBLIC HEALTH RESPONSE ACTIVITIES
health disaster teams provide valuable information
necessary for situational awareness, resource requests, The Atlantic hurricane season begins June 1 and
and actions necessary to bring lifesaving or critical sys- ends November 30. During this period, US coastal
tems to protect affected communities.13,14 states and Caribbean territories prepare for major
hurricanes. Storm intensity can range from a tropi-
Internal and external coordination and execution cal storm to a major hurricane capable of bringing
of these tasks require clear organization and com- destructive winds, storm surge, heavy rainfall, and
mand structure. Establishing and being part of an landslides.15 During September 2017, Hurricanes
incident management system (IMS) is an important Irma and Maria devastated Puerto Rico (PR) and the
first task. An IMS helps assemble and coordinate US Virgin Islands (USVI) in the Caribbean. As a cat-
resources from all jurisdictional levels in disasters. egory five storm with winds as high as 185 miles per
In the Irma and Maria response, the IMS structure hour, Hurricane Irma devastated much of the USVI
was fundamental in managing a variety of specialty and brushed the island of PR causing severe damages,
teams and activities from several agencies. For all dis- floods, and widespread loss of power.16
aster responses, the primary model for supporting and
Two weeks later, Hurricane Maria landed in the
USVI and PR as a category four storm, resulting

Special Issue on Puerto Rico

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

in additional impacts and damages in the already PHT initial task consisted of carrying out the initial
ravaged territories.17 The combined impact of these disaster assessment and established the initial coor-
two storms caused a collapse of the entire power dination with their public health counterparts in the
grid and left many residents with damaged homes. affected US territories. After evaluating the initial
In many cases, it also eliminated access to clean impacts of Hurricane Irma with the Puerto Rico
water and basic communications, such as phone or Department of Health (PRDOH), the PHT traveled
internet, and shut down businesses and health care to the USVI to support the USVI Department of
systems. President of the United States, Donald J. Health (VIDOH) in assessing needs. After hurricane
Trump, approved Major Disaster Declarations for the Irma landfall, VIDOH initial needs consisted of pub-
Caribbean Territories for the USVI on September 7, lic health resources to support shelter surveillance
2017, and for PR three days later.18,19 and disaster shelter assessments, augment clinical
support staff and surveillance, conduct vector control
HHS followed by issuing a declaration of public assessments, and implement vector control measures.
health emergency for the USVI and PR, allowing After Hurricane Maria landfall, they also requested
for the release of additional funding and resources support for incident management team operations
necessary to support the territorial response.20,21 (Emergency Operations Center (EOC), operations,
On September 10, 2017, HHS deployed an Incident and logistics), and environmental health monitoring.
Response Coordination Team (IRCT) (recently Initial observations revealed great impacts to medical
rebranded as “Incident Management Team” (IMT)) and public health infrastructure and services avail-
to PR and USVI to initiate Hurricane Irma ESF-8 able in the USVI.
Public Health and Medical Services operations in
both US territories. The IRCT uses the Incident The team’s work in the USVI lasted only a
Command System (ICS) prioritizing and organiz- few days as Hurricane Maria, then forecasted to
ing public health and medical services support and be a category four or five storm, presented a new
establishing the initial public health resources in the regional threat with potential to cause further dam-
management structure.22 The IRCT also represents age to already-affected areas.17 As a result, FEMA
the ESF-8 at the FEMA Joint Field Office or JFO. safety officials requested that response teams on
During large event responses requiring coordination the USVI, including the PHT, return to PR ahead of
with senior government officials, a designated Senior the storm to shelter in place. After Hurricane Maria
Health Official (SHO) representing HHS leader- made landfall in PR, HHS and the PRDOH identi-
ship accompanied the team. PR served as the initial fied additional needs for public health and medical
base for arrival and staging of teams and logistics assistance, increasing the requirements for staffing,
resources of the IRCT and for deploying resources to public health experts, equipment, and other material
the USVI. Often disaster conditions, limited transpor- resources. With the arrival of additional public health
tation resources, lodging availability in affected areas staff, the small PHT morphed into a public health
require a gradual arrival of emergency resources branch (PHB) to adequately manage the surge in
to help manage them safely and efficiently. While public health staff and resources deployed in support
resources were coordinated and deployed, IRCT sen- of the territorial responses.
ior leaders in the islands worked directly with the
local public health and medical officials in identifying The incident PHB management structure estab-
areas of immediate ESF-8 support. lished followed ICS concepts, principles, and account-
ability requirements (Figure 1). Most seasoned
Embedded within the IRCT was a small, multi- responders are familiar with this system’s flexibil-
disciplinary PHT with expertise in disaster epide- ity and corresponding modular ability to organize
miology (epi), environmental health and hazardous teams and their public health functions. The IRCT
materials, water system infrastructure assessment, provided logistical or administrative support to the
public information, and incident management. The PHB to carry out mission assignments. Planning

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Figure 1.  Organization of the PHB for Hurricane Irma and Maria in Puerto Rico and the US Virgin Islands.

and operations personnel embedded in the PHB inte- expertise in several areas, including water systems
grated public health activities with the overall IRCT assessment. Using water testing equipment, PHB
plans and operation objectives, while the IRCT Plans teams assessed the status of water systems in prior-
Section served as the final approval authority for all ity facilities. They began by collecting water samples
PHB field activities. Several operational divisions of to test for chlorine residual and coliform bacteria
HHS contributed specialists with expertise in emer- from the main water storage systems supplying the
gency management, epi/surveillance, health commu- San Juan Medical Center area. This medical complex
nication, environmental health, occupational health, consists of several specialty hospitals and centers and
and infectious diseases. The federal public health the only trauma center serving PR and the neigh-
staff also included staff with subspecialties in hazard- boring Caribbean islands. Staff from the PHB also
ous materials, food and water systems, vector control, assessed military facility water systems, assisted the
safety, immunizations, and laboratory sciences. IRCT safety team with evaluating responder billet-
ing, and joined the PRDOH in assessing the largest
ENVIRONMENTAL HEALTH ACTIVITIES disaster shelter near San Juan. Damaged pumps
and fuel shortages hindered access to potable water
Hurricane Maria left both PR and USVI with a for drinking and daily chores for most of the island.
range of complex environmental health issues and PR’s Aqueduct and Sewer Authority (PRASA) and
concerns, which were, and still are being addressed non-PRASA pumps, stations, and systems in very
by the joint efforts of various agencies and organiza- remote parts of the island were also inoperable. As
tions. The complexity of the environmental challenges a platform for coordination, the PHB joined FEMA
required effective coordination between the PHB, drinking water discussions, leading to stakeholder
PRDOH, VIDOH, and other territorial and federal agencies and organizations establishing a water task
agencies involved in the response. The majority of force. Team members participated in briefings held
the PHB consisted of environmental health special- by the water sector, co-led by the US Environmental
ists and engineers from various HHS operational Protection Agency (EPA) and PRDOH.27
divisions and national partner organizations with

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66 Journal of Emergency Management
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While efforts were underway to evaluate and The homes of many public health, medical work-
safely bring community water systems back online, force, and health department employees in PR were
territorial and federal public health stakeholders destroyed or damaged in the storm. VIDOH build-
also worked together with volunteer agencies and ings on the islands of St. Croix and St. Thomas
donors to provide or increase access to safe water. experienced ongoing rainwater intrusion and wors-
They launched a massive logistical effort to distrib- ening mold issues. The only hospital on St. Thomas
ute potable bottled water via ground and rotary sustained catastrophic damages, resulting in severe
aircraft to remote areas. Other efforts included using mold and hazardous materials contamination and
Department of Defense (DOD) mobile water purifica- concerns regarding potential radiation contamination
tion and treatment units, delivering water storage concerns. Other facilities of concern were schools, day
tanks to key access points for community members, care centers, restaurants, food distribution centers,
and distributing water purification tablets in very and grocery stores.
remote areas where the use of untreated water was
reported. The execution of these strategies success- The VIDOH PHT conducted environmental health
fully demonstrated the effectiveness of working in needs assessments focused on providing access to safe
communication efforts with a variety of partners. water, ensuring appropriate food handling practices
For example, environmental health team members at food service facilities, and monitoring proper tem-
worked with other agency counterparts on the com- perature at grocery stores and food stations. Health
munications team to prepare bilingual, culturally surveillance at disaster shelters monitored and iden-
appropriate messaging and materials describing how tified harmful conditions, unusual injuries, or poten-
to use water purification filters and tablets. Spanish- tial outbreaks of communicable disease. Other pre-
language media campaigns were launched to clarify ventive activities included health communication
issues with hyperchlorination of drinking water. efforts focusing initially on water decontamination,
household cistern remediation, safe mold clean up,
In the USVI, Hurricane Irma initially devastated generator use, and food handling and disposal.
St. Thomas and the small island of St. John; then,
Hurricane Maria compounded the impacts to buildings Following disasters, monitoring and disease con-
and services such as health department and health- trol services, may be required. Including this infor-
care facilities and schools on the first two islands mation in environmental assessments and surveys
and the island of St. Croix. The VIDOH buildings helps identify and evaluate vector-borne disease risk
suffered extensive water and wind damage. Debris, factors.3,23 Federal assistance for vector surveillance
power lines, and solid waste littered most of the roads, and control is available from FEMA, with recom-
public buildings, and schools, creating environmental mendations from the Centers for Disease Control
hazards. Residents had no access to power or safe and Prevention (CDC) after certain risk-evaluation
water. Communication system towers were destroyed, criteria are met. The issuance of a post-disaster vector
limiting phone and radio communication to and from control recommendation enables jurisdictions to work
the islands. In the USVI, the reduced environmental with authorities, including DOD, when more enhanced
health staff and severe post-storm damage limited prevention and control strategies are necessary.24,25
VIDOH’s ability to assess and respond to environ-
mental health challenges. The VIDOH and PHT rec- An increased mosquito population following a hur-
ognized that environmental health need assessments ricane or flood is common phenomenon, so the PRDOH
would be crucial in identifying the most urgent issues made vector control a priority in the Hurricane Maria
for community members, particularly for those with response. A major concern was the presence of Aedes
pre-existing health conditions. As a result, assess- aegypti, a mosquito species endemic to the Caribbean
ments of access to clean water, safe food, and vector region and capable of transmitting dengue, zika, and
control immediately became public health priorities. chikungunya. Well-documented outbreaks of these dis-
eases in PR and the USVI added to the sense of urgency
for increased monitoring activities.25,26 To assist with

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these efforts, the PHB requested and deployed vector surveillance sites were established in other munici-
control specialists to assist the PRDOH and VIDOH. palities. Despite general concerns, public health
Teams conducted rapid assessments to evaluate the partners determined the potential for vector-related
vector control programs and met with senior-level issues was low, based on the data collected from those
emergency management, government officials, and sentinel sites.
industry leaders to discuss vector control services and
prevention of vector-borne diseases. The impacts of both DISEASE SURVEILLANCE, PREVENTION, AND CONTROL
hurricanes affected mosquito control program facilities.
Several regional offices and warehouses of the PRDOH Survivors in post-disaster conditions may face
mosquito control program reported structural damage ongoing health risks from poor sanitation and lack
and loss including buildings, equipment, vehicles, and of access to safe food or water. The loss of home pro-
supplies. Members of the team worked directly with tective barriers, increased human-animal interac-
organizations to document damage and loss and use the tion, and other health challenges. Integrating mul-
information to request funding from FEMA under vari- tijurisdictional public health expertise into disaster
ous public assistance programs for mitigating struc- response can help mediate these concerns and moni-
tures and performing temporary or permanent repairs. tor associated risks. Although, PRDOH was able to
maintain parts of the local surveillance system in
PHB staff with expertise in vector control worked operation, reporting lags due to damages to commu-
with the Joint Information Center (JIC) and with the nication systems and IT and damage to the public
PHB communication team to create messaging about health laboratory limited their ability to confirm
the importance of the use of mosquito personal protec- infectious diseases quickly. Impacts to laboratory
tion measures and to enlist the public’s assistance in equipment and testing equipment required outside
eliminating potential breeding sites for mosquitoes. assistance to help confirm diagnoses.
The team also led discussions on the importance of
debris cleaning, water draining, and public education. To address these post-disaster challenges, the
Additionally, some types of vector control methods PHB Epi/Surveillance Team implemented enhanced
were a concern. For example, an estimated 60-70 surveillance at several Veterans Administration (VA)
percent of USVI residents used rainwater collection and DOD facilities. The PRDOH and PRB worked
systems in their homes, and aerial or truck-based with the VA to collect individual and aggregate-level
spraying could contaminate the water. data for surveillance purposes. Epi/Surveillance team
personnel conducted individual level syndromic sur-
Even before the storms, the capacity for vector veillance by abstracting data from medical records at
surveillance and control was limited. The VIDOH three VA locations. Additionally, the team collaborated
worked with neighboring Caribbean partners who with DOD to collect aggregate-level surveillance data
provided in-kind support for vector control. However, from DOD temporary field medical treatment sta-
limited data on mosquito surveillance information tions. Data from DOD, and VA hospitals, clinics have
affected the immediate evaluation and assessments been used in syndromic surveillance since the 2001
of vectors. For example, FEMA requires submission terrorist attacks. In PR, Disaster Medical Assistance
of vector activity data along with requests for vector- Teams (DMAT) operated medical treatment sites/
control assistance, but baseline or background data federal medical stations (FMSs) locations around
were not immediately available. The PRDOH, DOD, the island, which reported data into the Electronic
the PR Vector Control Unit, and staff from the CDC Surveillance System for the Early Notification of
Dengue Branch located in PR conducted mosquito Community-based Epidemics (ESSENCE).27,28
trapping and surveillance and mapped sites that
showed increased mosquito activity. Initial mosquito DOD medical treatment throughout the island
surveillance efforts took place in large urban areas also included operations in temporary sites and the
in San Juan, Mayaguez, and Ponce; later, additional US Navy Ship Comfort. These facilities submitted
daily aggregate syndromic surveillance reports to

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the PHB epi/surveillance team, including counts of of waterborne and epizootic disease. A higher risk of
infectious disease syndromes, acute mental health exposure to leptospirosis was an immediate concern
symptoms, acute injury conditions, and “other” ill- because of increased human contact with floodwa-
nesses. For their daily surveillance reports, the ters, unsafe water consumption, and the presence of
PHB pulled illness data from ESSENCE, including rodents in damaged homes. During past hurricanes
fever, gastrointestinal illness, influenza-like illness, in the island, the PRDOH documented considerable
injuries, and respiratory syndromes. The PHB had increases in leptospirosis cases.29 As a result, authori-
a limited role in surveillance of infectious diseases ties increased prevention education for the public and
and other health conditions in nonfederal sites, as physician education for managing suspected cases.
many of these activities were under the purview of
the territorial health agencies; this information was Health concerns about potential for increased risk
not accessible, and therefore, not included in the PHB of exposure to rabies, prompted requests for procur-
surveillance report. ing additional animal and human rabies vaccinations
from the US Department of Agriculture National
These data collection efforts demonstrate that Veterinary Stockpile.30 In PR, rabies is endemic in the
public health surveillance, in collaboration with all mongoose population, and both human and animal
public health and medical partners in theater, is criti- rabies cases are well documented.31,32 Loss of struc-
cal in monitoring potential threats. Although PHB tural protection at homes, and disruption of animal
public health surveillance efforts were limited, access habitat after a storm may increase human-animal
to the PRDOH and VIDOH epidemiology/surveillance contact. In PR, the PHB received also multiple reports
staff provided a reasonable view of the most critical from field teams about stray cats and dogs coming in
health issues occurring at sentinel sites. PHB met close contact with shelter occupants in some facilities.
often with PRDOH epidemiologists to assess and dis- The PHB helped secure additional vaccines until a
cuss any surveillance support needs. steady resupply was established. In the USVI, the dis-
covery and subsequent confirmation of two diseases,
In the USVI, residents were concerned about leptospirosis, and mellidiosis, led to concerns regard-
emerging public health issues caused by power loss, ing exposure to contaminated or untreated water.
poor living conditions, eg, homes with no roofs, These included public health surveillance, vector
continued rain and standing water, and infrastruc- control, and information distribution to help citizens
ture damage to transportation, potable water, and avoid additional health risks.
healthcare. During the aftermath of these storms, the
VIDOH staff collaborated with shelter volunteers to HEALTHCARE FACILITY AND COMMUNITY
implement a surveillance system using the existing
Red Cross Aggregate Morbidity (Tally) form to tally POST-IMPACT NEEDS ASSESSMENTS
daily client visits from each shelter. Data collected
between September and October 2017 from the three Assessments of healthcare facilities are an essen-
shelters on St. Croix and two on St. Thomas provided tial task in any post-disaster setting. The World
the VIDOH with one of the only sources of evidence- Health Organization encourages adopting initiatives
based, near real-time public health data available such as the “Safe Hospitals” framework to ensure
during the response and helped guide response and hospitals and health facilities are safe in preparation
recovery efforts to protect community health. and or following disasters and to maintain continuity
of essential operations for the local population and
Other health concerns in the affected territories responders who may deploy to the response location.33
included the re-emergence of endemic diseases, such
as leptospirosis and rabies. Destruction of physi- Health care facilities (HCFs) routinely serve
cal barriers between residents and the environ- those affected by injury, illness, and chronic health
ment, lack of potable water, and large amounts of conditions, such as kidney failure. However, after
debris created concerns about potential outbreaks disasters, in addition to providing medical care to
affected communities, HCFs take on enhanced roles,

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including comforting victims and serving as a distri- returning to the PHB, which was located at the FEMA
bution and resupply point for medicine and oxygen. Joint Field Operations (JFO). Because this task was
Disruptions to healthcare services can result in urgent, teams initially used an existing paper version
increased mortality as well as exacerbated illness and of a hospital assessment tool and a modified version for
chronic disease conditions. Loss of hospital care can assessing smaller facilities such as healthcare centers,
mean loss of lifesaving medications and treatment for which did not have a hospital’s wider scope of services
people with chronic conditions, such as diabetes and and complex unit areas. The initial needs assessment
hypertension, and for those requiring dialysis and tool documented facility structural damages, opera-
respiratory or mental health services. Long delays in tional status of various hospital service units, and
electrical service restoration quickly render medica- utilities or power generation when applicable. Also, the
tions and vaccines unusable, endanger those at risk tool identified other immediate resource and supply
of overheating without air-conditioning, and dam- shortfalls including medical supplies, personal protec-
age facility systems sensitive to rising temperatures tive equipment, medications, oxygen, fuel, staffing, and
such as operating suites, negative pressure rooms, support for facilities requiring medical evacuation.
air conditioning, and septic systems.34 As a result,
the PRDOH and HHS/IRCT made HCF evaluation a As the response progressed, the HCF tool was
primary PHB mission.35 modified to accommodate specific information needs
of response agencies providing support to these facili-
After the hurricanes, the PHB was requested by ties. Other information collected included patient
the IRCT leadership to support local public health census, beds lost because of hurricane-related dam-
authorities by conducting post-impact assessments age, morgue spaces available, and number of bodies
in PR and USVI HCFs. In September 2017, approxi- held in the morgue. The information collected was
mately 66 hospitals and 215 healthcare centers in PR used to validate requests for supplies, equipment,
required assessment. In the USVI, the task involved and other necessary resources to operate the facilities
assessing two hospitals, one in St. Thomas and one in and monitor issues like morgue capacity. Overall, the
St. Croix. Several HCF assessment teams, consisting team completed assessments of most HCFs in PR:
of environmental health specialists, sanitarians, and 64 hospitals (97 percent) and 187 HCFs (85 percent).
engineers, undertook this large operation in PR and
the USVI. Because of safety issues, curfews, and aus- The final part of the operation included enter-
tere post-disaster conditions, the teams were initially ing the data and providing a brief report of critical
allowed to conduct field activities only when escorted information and immediate needs to the PRDOH,
by law enforcement. They had high frequency radios FEMA, and HHS. Data capture, analysis, and report-
and satellite phones; however, outside the metropoli- ing improved significantly later in the response,
tan area of San Juan, most cellular and even satellite expedited by the use of an app-based survey tool
phone service was unavailable. Damage to roads and that allowed for faster database population and data
bridges required numerous detours, making car travel visualization via dashboards. The teams also reported
dangerous and time-consuming and causing delays safety, logistical, and communication challenges when
in collecting this critical information. The DOD and traveling around the island, including long lines for
Department of Homeland Security (DHS) made rotary refueling, lack of reliable physical location informa-
wing aircraft, such as helicopters and Osprey, available tion, and lack of Spanish-speaking public health staff.
as alternate means of transportation for field teams.
The PHB also assessed FMS sites and conducted
To ensure internal consistency of all HCF assess- preoccupancy assessments of potential sites. FMS
ments and data collection, PHB staff trained all field sites are temporary medical facilities capable of caring
team members in using the assessment tool and meth- for 50-250 people who require a safe location and suit-
ods and led the facility assessment process. Teams able wrap-around services such as power, water, and
were briefed twice daily, prior to departure and upon sewage. They provided temporary shelter for evacuees
from nursing home and long-term care facilities who

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70 Journal of Emergency Management
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required basic levels of healthcare and monitoring.36 public health impacts in communities before, during,
After two major hurricanes, many potential FMS loca- and after the hurricanes. The information collected
tions were not fit for human occupancy. The compre- by the CASPERs assisted the VIDOH, the Virgin
hensive safety and operational assessments that PHT Island Territorial Emergency Management Agency,
conducted were critical for ensuring FMS facilities and other partners in developing a long-term hur-
could safely house patients and caregivers. ricane recovery plan. CASPER baseline information
helped monitor ongoing recovery efforts following the
During this response, the PHB was invited to par- storms, and the VIDOH conducted a follow-up recov-
ticipate in interagency discussions identifying needs ery CASPER in February 2018.
in isolated communities (ICOS) in the mountains
of PR left inaccessible by the storms. DHS was able HEALTH AND RISK COMMUNICATIONS
to identify those at-risk communities during search
and rescue operations and aerial surveys. The PHB HHS supported deploying CDC health commu-
listened to the concerns and proposed to assist the nication specialist teams to PR and the USVI to pro-
group by deploying teams to assess and document vide direct support to the public health departments.
needs in those communities. The CDC has developed During large-scale incidents, response agencies may
a disaster assessment method known as Community assign communication and media staff to a JIC to
Assessment for Public Health Emergency Response assist with coordinating and creating cohesive key
or CASPER for disaster situations. This method is preventive messages and information. These special-
designed to provide timely, inexpensive, and repre- ists worked alongside PRDOH, HHS media special-
sentative household-based information about com- ists, and the FEMA JIC at the San Juan Joint Field
munity needs.11 The PHB adopted a CASPER-like Office to develop educational materials and to dis-
tool and interview approach to gather information seminate clear, timely, science-based, post-hurricane
from households in the ICOS. Logistics and trans- messages on health promotion, and disease preven-
portation were coordinated by DHS and DOD. They tion. The health communications team created a com-
facilitated access to dedicated aircraft to transport munication plan with multichannel strategies, tactics,
members of assessment PHB teams to these remote and tools that included printed materials, community
areas. The team members traveled mostly by foot to outreach events, print and radio interviews, video/
interview residents to complete de assessments. The photography, and social media campaigns. The assess-
assessment tool used by the PHB to record household ment of health information needs as a result of the
interviews included questions about illnesses/deaths, environmental effects of Hurricanes Irma and Maria
resource and commodity needs, and access to informa- identified gaps regarding risk- and hazard-specific
tion about health and social services. Upon return, information. The PHB worked with the JIC or directly
teams provided a daily summary of key findings to with PRDOH Office of Communications in producing
both DHS and IRCT for both planning purposes and health communications materials in post-event safety,
delivery of any needed resources and supplies. The infectious disease prevention, water and food safety,
ICOS team also recommended conducting formal and exposures to air pollutants, including carbon
CASPERs in more affected communities. The infor- monoxide hazards.
mation generated by CASPERs can be used to initi-
ate public health action; facilitate disaster planning, As the response issues evolved, the team also
response, and monitoring recovery activities; and created, printed, and assembled packets of CDC and
assess new, changing, or emerging needs during the PRDOH cobranded health education fact sheets on
disaster recovery period. food and water safety, leptospirosis, mold, and mental
health. All materials were translated and reviewed
In the USVI, the VIDOH conducted two CASPERs for Puerto Rican Spanish and cultural appropriate-
in November 2017 to assess USVI residents’ hur- ness. During 30 community outreach events held
ricane experiences during Irma and Maria and the throughout the island, the PHB communication team

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distributed over 1.5 million fact sheets in shelters, word of mouth. Leveraging response efforts with the
disaster recovery centers, military distribution cent- PRDOH, FEMA, Red Cross, and other key partners
ers, clinics, hospitals, schools, and homes in rural and proved to be an effective strategy for cohesive messag-
isolated communities. ing. Finally, assembling a team of experienced, flex-
ible, and culturally sensitive communicators, many of
The communications team in PR also assisted with whom were natives of PR, was critical in implement-
streamlining the processes for the PRDOH, FEMA, ing public health strategies, especially during the
and CDC scientific and communication experts to vet initial chaos that so often follows a disaster.
and approve public health materials and key mes-
sages. For example, public affairs and FEMA JIC RESTORATION OF PUBLIC HEALTH SERVICES AND SYSTEMS
officers worked together creating public health mes-
sages and health education materials highlighting Restoring preventive services and systems after
risks associated with disasters, eg, carbon monoxide. any large disaster begins in the response phase and
In addition, PHB health communication staff assisted continues through recovery. The backbone of any pub-
the PRDOH in developing statements addressing lic health disaster response is the ability to quickly
rumors about cholera outbreaks in communities. The determine which issues have the greatest potential
team worked with PRDOH and CDC cholera experts to affect communities and emergency responders. An
to construct the appropriate messages and factual interruption in key public health systems and preven-
statements to control the misinformation and reas- tive services, even for a short period in a nondisaster
sure the public. After a few HCFs reported suspected situation, can threaten public health. After these hur-
cases of leptospirosis, the team helped develop a stra- ricanes, those systems were left severely degraded
tegic communications plan for health education; coor- for months. An increased risk of disease could result
dinated clinician outreach presentations and calls; from delayed or absent systems such as routine and
arranged media interviews with local health and CDC seasonal immunizations, treatment and diagnosis
experts; and produced fact sheets, posters, public ser- of chronic and infectious conditions, food and water
vice announcements, and social media messages. quality monitoring, and laboratory testing. During the
aftermath of Hurricane Irma and Hurricane Maria,
Despite the communication infrastructure chal- the PHB coordinated the deployment of assessment
lenges in PR, the team successfully evaluated, and teams to evaluate operational capacity and damage to
adapted their communication strategies based on public health facilities and established a framework
feedback and information gathered, mostly in person, for transitioning information about those impacts to
about public health issues occurring in the impacted the recovery phase.
communities. As a result, residents began receiving
timely and critical public health information, allow- The first step was establishing a restoration of
ing them to make informed decisions to protect them- services team as part of the PHB, which included
selves and their families. The team strategies relied members of several federal agencies such as FEMA
heavily on distribution of printed materials and direct and several HHS Operating Divisions, which con-
community-based health promotion and outreach, tributed large numbers of environmental health
which effectively reached at-risk individuals and com- specialists and facility engineers. The team focused
munities with the right messaging. on several areas of restoration: laboratory capac-
ity, immunizations, critical public health facilities
The team also identified social media groups (including those providing immunizations, HIV/STD
formed by Puerto Ricans in the US mainland (known diagnosis, and treatment), and environmental health
as “la diaspora”) who relied on technology to connect services. The need was clear as the PRDOH labora-
with family and help people on the island. These tories (a network that consists of three regional and
outlets could target health prevention messages and one main laboratory), suffered significant structural
post relevant digital messages on the Facebook group damage and environmental contamination from the
platforms that could be relayed to people in PR by

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72 Journal of Emergency Management
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direct impacts of wind and water intrusion.37 Because FEMA BRANCH LIAISON SUPPORT
of these impacts, laboratories could not provide sev-
eral testing services, including tests for food, water, Immediately after the storm, FEMA divided the
and infectious disease. Power outages resulted in municipalities of PR into four branches. Staff from the
additional losses as sensitive equipment and supplies PHB were reassigned to fulfill roles as public health
could not be maintained at the required temperatures liaisons to these branches and provide additional
or humidity or appropriately quality controlled for oversight and awareness of local issues. Additionally,
accuracy. The PHB coordinated a request for CDC this allowed PHB staff greater access to better infor-
staff to provide laboratory technical staff to PR to mation and more interaction with municipal agencies
assist with the inventory of damages. The Association and communities about public health needs. However,
of Public Health Laboratories, an organization that finding enough bilingual public health staff to fulfill
assists with coordinating emergency responses and those roles and securing lodging and communication
assistance to such facilities, sent a four-person team with the embedded teams proved to be problematic
to PR assist with the public health laboratory system when most communications and utilities outside the
assessment. San Juan metro area were still down. As a result,
some of the liaison staff commuted from their base in
In addition to damaged equipment and supplies, San Juan several times a week to provide technical
many other systems necessary to safely operate a assistance to the branches.
laboratory suffered damage or were contaminated,
including HVAC systems, roofs, towers, and safety DISCUSSION
hoods. Testing was suspended for several conditions
important to public health, so the PHB assisted The disastrous impact of Hurricanes Irma and
with the initial coordination of delivering specimens Maria followed a reprieve of approximately 15
for testing at CDC laboratories, located in Atlanta, years since the last major hurricane struck the US
Georgia. The massive power loss also damaged stocks Caribbean territories. The isolation and vulnerabil-
of vaccines in storage, including seasonal flu and rou- ity of the islands presented potential challenges and
tine children and adult immunizations. A seasonal logistical concerns that are inherent in this area and
flu vaccination campaign, scheduled to begin only a that must be considered in future planning. Perhaps,
few weeks after the storms, was postponed until ade- a practical approach for enhancing collaboration
quate supplies of vaccine and materials were made and assistance in disasters between islands, some
available. Other severely affected facilities included within close distance of each other, maybe the use of
PRDOH headquarters and specialty clinics serving a “whole of regional community” response approach.
populations such as young children and people with This approach may reduce the time required for
disabilities. initial evaluation of impacts by neighboring islands
before additional help arrives. The Irma and Maria
Throughout the transition to recovery opera- responses required a multi-agency, coordinated effort
tions, the PHB supported the PRDOH and helped that faced unique challenges not typical of hurricane
to facilitate requests for a constant influx of experts responses in the mainland US—for both victims and
and consultants to help complete required damage emergency responders who faced the same shortages
and cost estimate assessments for FEMA. Data and of supplies and resources.
information gathered during those damage assess-
ments allowed for faster allocation of funds for tem- The public health response to Hurricane Irma
porary repairs and initial recovery. Records, pictures, and Hurricane Maria also highlighted the unprec-
narratives of all damages, and cost estimates were edented efforts by public health partners to confront
provided to the PRDOH, Army Corps of Engineers, and adapt to challenges. Complex disasters require
FEMA, and other agencies assisting with damage standard tools and methods that are easy to under-
quantification. stand and implement even in slow or acute onset
disaster situations. The public health agencies in

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theater successfully adapted to the changing situa- of the PHB, DOD, and local law enforcement agencies
tion and logistical difficulties to focus on upcoming provided teams with safeguards to allow them to focus
challenges, assess gaps, and adopt an organizational on the mission ahead. Whenever necessary, these liai-
framework for running a safe and effective opera- sons also coordinated air and ground mobility using
tion. Establishing an incident management structure, DOD or DHS aircraft to transport the teams to remote
based on effective and focused field activities, helped areas of the island. In addition, DOD, VA, and HHS
IRCT leadership, other federal teams, and partners all collaborated in the public health mission in sev-
understand the scope of PHB missions. eral ways including development and sustainment of
a surveillance system, participation in vector control
The public health partners in theater successfully surveillance and control, and initial transport of labo-
adapted and used existing tools and methods such as ratory samples to CDC for analysis.
public health assessments tools, surveillance concepts,
to and communications materials. For example, while Deploying a wide range of senior public health
conducting shelter assessments, the field team used specialists with diverse experience as part of the ini-
the CDC tool for disaster shelters. For HCF assess- tial team was critical for the team’s success. Personnel
ments, a paper assessment tool was used for the ini- supporting ESF-8 functions bring a wealth of multi-
tial evaluation of operational capacity, damages, and disciplinary expertise to a disaster response. During
needs. During the ICOS mission, teams adapted the this response, drawing upon that range of expertise
questionnaire from CDC’s CASPER.11 Teams modi- on the ground improved mission performance and
fied the tools only to add additional information for allowed the experts a firsthand view of the issues.
leadership to address emerging needs, such as data Some issues are unavoidable and both territorial pub-
on morgue capacity and fuel levels. lic health agencies needed assistance in coordinating
data and information collection. However, efforts
Often from necessity, new ideas for improving toward improving and supporting those systems are
disaster tools and processes may emerge from team ongoing through the on-going recovery phase.
members doing the actual work. For example, teams
felt burdened by the task of entering data after In the VIDOH, a variety of issues resulted in
returning from fieldwork. The PHB leadership worked delays implementing vector control. Teams were
with response agencies, including FEMA and the PR required to submit a plan of activities to the safety
Planning Board, to develop and implement app-based officer for approval before traveling to other parts of
survey tools for the HCF assessments. The tools the island. Teams often experienced significant delays
reduced the time that took to enter the data, often up because of logistics, limited fuel, or safety conditions
to 45 minutes, and expedited availability of critical in the field. Roadblocks, detours, and damaged roads
information. During this response, members of teams required both additional time and fuel, forcing teams
doing field assessment activities were trained to use to end their work prematurely. The situation began
the field tools and tablet-based assessments. As a leg- to normalize after FEMA established several fuel-
acy of this collaborative response, the PRDOH began dispensing points around the island for responders.
actively improving and exercising their automated
HCF data systems during recovery. During this event, the PHB encountered several
challenges, many of which were jurisdictional or
Safety in any disaster field operation is paramount. agency specific. Though the PHB had surveillance
In natural disasters, the loss of common safeguards, and environmental assessment tools and trained
such as communication networks and safe roads, pose staff to support those activities, access to congregate
additional challenges to the safety of field workers shelters located around the island of PR to assist with
and may limit their ability to travel to the affected assessments and surveillance activities was limited.
sites. In PR, the environmental and structural damage One way to improve this collaboration in future may
inhibited cellular and electronic communication and be to establish pre-impact agreements or memoran-
impeded access to field sites. The effective collaboration dums of understanding to support and facilitate the

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74 Journal of Emergency Management
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exchange and access of surveillance information from All disasters are different; however, disaster
the local jurisdiction. response starts with evaluating available public
health systems and developing a prioritized schedule
In addition, in PR the PHB struggled through- of targeted activities. During this large, complex dis-
out the response to maintain an adequate pool of aster response, public health activities were funda-
Spanish-speaking public health workers. Fieldwork mental in providing data and information for action
required conducting interviews and participating on public health areas. The information collected was
in community meetings and outreach activities in also instrumental in ensuring a smooth transition
which community leaders, mayors, and organizations into the recovery phase and help with restoration of
exchanged views and information. Bilingual staff public health capabilities system and services. The
capable of fluently communicating and actively par- response to Hurricanes Irma and Maria validated the
ticipating during those meetings were in short supply. contributions of emergency public health components
Although FEMA did provide in-kind assistance with across different sectors in promoting the health and
translators, many were not specifically trained in wellbeing of everyone affected by a disaster.
public health. Preplanning for a disaster response in
an area where most of the residents speak a language Acknowledgment
other than English should include recruiting bilin- We would like to acknowledge the work of all the staff from the
gual, qualified public health workers. following agencies who supported the initial response activities of
the public health branch: Health and Human Services, Centers for
Finally, whenever possible, advance PHTs Disease Control and Prevention, Food and Drug Administration,
should be deployed pre-event. Advance deployment Indian Health Service Health Resources Administration, Agency
would improve early coordination and integration for Children and Families, Bureau of Prisons, US Department of
or resources with local and response stakeholders, Homeland Security, US Department of Defense, Department of
provide an opportunity for early planning of needs Veterans Administration Hospital and Clinics, the PR Science Trust,
assessments, and build the relationships and organi- Federal Protective Service, US Public Health Service Commissioned
zational concepts for running a safer and effective dis- Corps, PR Rico National Guard, and Puerto Rico’s State Agency for
aster response, and subsequently, a swift transition to Emergency Management and Disaster Management (AEMEAD).
recovery work. Disclaimer:  The findings and conclusions in this article are
those of the authors and do not necessarily represent the official
CONCLUSION position of the Centers for Disease Control and Prevention. The
authors have no conflicts of interest.
Overall, the PHB demonstrated its utility as a
primary resource during and after two major back- Miguel Angel Cruz, PhD, National Center for Environmental Health,
to-back disasters affecting both the US Virgin Islands (Now) Agency for Toxic Substances and Disease Registry, Centers for
and Puerto Rico. Public health tools and methods Disease Control and Prevention, Atlanta, Georgia.
utilized displayed the simplicity and adaptability of
disaster assessments and other types of monitoring Luis O. Rivera-González, PhD, Toxicologist, Region 2, Office of
systems in disasters. The systematic integration of Community Health and Hazard Assessment (OCHHA); Agency for Toxic
public health activities with governmental, volun- Substances and Disease Registry (ATSDR); Centers for Disease Control
teer, and military resources in PR and the USVI and Prevention (CDC), New York, New York.
can served as a model for future disaster planning,
regardless of event. For example, disaster relief and Elizabeth Irvin-Barnwell, PhD, Agency for Toxic Substances and
nongovernmental organizations such as Americares, Disease Registry, Centers for Disease Control and Prevention, Atlanta,
the CDC Foundation, the Association of Public Health Georgia.
Laboratories, Mercy Corps, the PR Science Trust, the
CDC Dengue Branch in PR, and many others dem- Jessica Cabrera-Marquez, PhD, Public Health Emergency Preparedness
onstrated how a unified effort can make a difference and Response Program, Puerto Rico Department of Health, San Juan,
during a major disaster event. Puerto Rico.

Esther Ellis, PhD, Epidemiology and Disease Reporting Program,
Territorial Public Health Laboratory, Virgin Islands Department of
Health, St. Croix, US Virgin Islands.

Brett Ellis, PhD, Territorial Public Health Laboratory, Virgin Islands
Department of Health, St. Croix, US Virgin Islands.

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Benjamin Qi, PhD, US Army Medical Research and Development 7. CDC: Infectious disease and dermatologic conditions in evacu-
Command, Ft. Detrick, Maryland. ees and rescue workers after hurricane Katrina—Multiple states,
August—September 2015. MMWR. 2005; 54: 961-964.
Christopher Maniglier-Poulet, MS, Agency for Toxic Substances and 8. Friedrich MJ: Determining the health effects of hazardous
Disease Registry, Centers for Disease Control and Prevention, Atlanta, materials released during hurricane Harvey. JAMA. 2017; 19:
Georgia. 2218-2285.
9. Sengul H, Santella N, Steinberg LJ, et al.: Analysis of hazardous
Justin Andrew Gerding, DHA, National Center for Environmental materials due to natural hazards in the United States. Disasters.
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10. Cruz MA, Garcia S, Chowdhury MA, et al.: Assessing the con-
Alice Shumate, PhD, National Institute of Occupational Safety and gregate disaster shelter: Using shelter facility assessment data
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Infectious Diseases, Atlanta, Georgia. for public health emergency response (CASPER): An innovative
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Jonathan Yoder, MPH, National Center for Emerging & Zoonotic Health. 2017; 107: S186-S192.
Infectious Diseases, Atlanta, Georgia. 12. Cruz MA, Rubens M, Garcia SJ, et al.: Knowledge of and prepar-
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for Disease Control and Prevention, Atlanta, Georgia. ments survey. Disaster Med Public Health Prep. 2017; 11: 11-14.
13. Kirsch TD, Mitrani-Reiser J, Bissell R, et al.: Impact on hospital
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Control, Centers for Disease Control and Prevention, Atlanta, Georgia. Public Health Prep. 2010; 4: 122-128.
14. Nour M, Alhajri M, Farag EABA, et al.: How do the first days
Tesfaye Bayleyegn, MD, National Center for Environmental Health, count? A case study of Qatar experience in emergency risk commu-
Centers for Disease Control and Prevention, Atlanta, Georgia. nication during the MERS-CoV outbreak. Int J Environ Res Public
Health. 2017; 14: 1597. DOI: 10.3390/ijerph14121597.
Carolina Luna-Pinto, MPH, National Center for Emerging & Zoonotic 15. National Hurricane Center: Tropical cyclone climatology.
Infectious Diseases, Centers for Disease Control and Prevention. NOAA Website. Available at https://www.nhc.noaa.gov/climo/#bac.
Accessed October 23, 2020.
Luis Orlando Rodriguez, MS, National Center for Environmental 16. NY Post Website: Hurricane Irma makes landfall in the
Health, Centers for Disease Control and Prevention, Atlanta, Georgia. Caribbean as a category 5 storm. Available at http://www.weather.
gov/sju/maria2017. Accessed October 25, 2020.
Joseph Roth, MPH, Center for Preparedness and Response, Centers 17. NY Post Website: Hurricane Maria September 20. 2017. Available
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caribbean-as-a-category-5-storm/. Accessed October 25, 2020.
John Bermingham, MS, Center for Preparedness and Response, 18. FEMA Website: Virgin Islands Hurricane Maria (DR-4340).
Centers for Disease Control and Prevention, Atlanta, Georgia. Available at https://www.fema.gov/disaster/4340. Accessed October
25, 2020.
Renée H. Funk, DVM, Agency for Toxic Substances and Disease 19. FEMA Website: Puerto Rico Hurricane Maria (DR-4339).
Registry, Centers for Disease Control and Prevention, Atlanta, Georgia. Available at https://www.fema.gov/disaster/4339. Accessed October
25, 2020.
Murad Raheem, BS, Office of the Assistant Secretary for Preparedness 20. HHS Website: Secretary price declares public health emergency
and Response, Department of Health and Humans Services, New York in Puerto Rico and US Virgin islands due to Hurricane Irma.
City, New York. Available at https://www.hhs.gov/about/news/2017/09/06/hhs-secre
tary-price-declares-public-health-emergency-puerto-rico-us-vi-due-
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October 25, 2020. October 21, 2020.
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25. Simpson JE: Emergency mosquito aerial spray response to the 31. Everard CO, Everard JD: Mongoose rabies. Rev Infect Dis. 1988;
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Inform Decision Making. 2011; 11: 56. DOI: 10.1186/1472-6947-11-56. Evaluating disaster damages and operational status of health-care
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Notes

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JEM Factors affecting the post-disaster temporary
housing construction

Mahdi Afkhamiaghda, PhD candidate
Emad Elwakil, PhD, PE, CCE, PMP

Kereshmeh Afsari, PhD
Randy Rapp, DMgt, PE, CCP

ABSTRACT and more people.1,2 According to the International
Displacement Monitoring Centre (IDMC), 14 million
Every year, around 14 million people become home- people annually lose their homes due to natural disas-
less worldwide due to natural disasters. Providing ters.3 In these situations, providing affected families
temporary housing for the affected people is consid- with temporary housing is considered a top priority.4
ered a complex task as it is affected by numerous fac- However, there have been many reports and incidents
tors such as socioeconomic, logistics, and community of these temporary houses not meeting the necessary
characteristics of the region. Acknowledging and cre- social and safety requirements of a good lodging place,
ating a balance between these needs by the agencies delayed, and being costly.5,6 Creating post-disaster
or contractors who provide accommodations to post- temporary houses is considered an arduous task.7-9
disaster victims is one of the main challenges that Besides, in the last century, two major factors have
need to be addressed. Although many research efforts contributed to the importance of temporary housing:
have been made regarding studying the factors, there (1) the increase of natural disasters both in destruc-
is a lack of reviewing these factors in detail and how tion and occurrence; according to several research
they can affect each other. This review paper studies works, the frequency of natural disasters is increas-
the factors affecting the building process of temporary ing in a way that they are becoming more of a norm
housings. It highlights the type and frequency of the than a rare occurrence;10-12 and (2) as the population
factors that have been studied by different research- increases, more people are now living in urban com-
ers and agencies in the past 20 years (1999-2019). munities. With the population growth in the modern
The resources used for this research were “Academic time, people now tend to live in cities more than ever,
Search Premier” and “Engineering Village” databases, especially the coastal lines where cities are experienc-
as well as the gray literature. It also provides a com- ing a high density and population increase.13
prehensive review of research and reports that have
studied the combination of these factors and how they There is no concrete definition of “adequate
have covered many of them. quality” for the post-disaster temporary housing.
Therefore, depending on numerous factors such as
Key words: temporary housing, post-disaster the magnitude and type of the disaster,14 location,
r­ ecovery, resiliency logistics, and community characteristics such as cul-
ture, population, density, and climate conditions of
INTRODUCTION the region,15 decision-makers will face different issues
and challenges.
Natural disasters are inevitable. Every year,
we are witnessing numerous hurricanes, earth- Some research work has presented a review of
quakes, and tornadoes worldwide; incidents have factors that affect the temporary housing process.
been increasing in frequency over time, affecting more

DOI:10.5055/jem.0632 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 79

However, there is a lack of reviewing how these fac- study. The search included high-ranked peer-reviewed
tors can affect each other.16,17 journals, conference proceedings, and most cited docu-
ments. In this step, the researchers first wanted to
This study has provided a comprehensive review gather information on “resiliency” and “temporary
of the factors studied by researchers and official housing,” making these two the primary keywords
reports in the last 20 years. Besides, it provides a they searched in the database separately. To broaden
breakdown and analysis of the factors’ frequency the range of search and the information retrieved in
to see which factors have been studied more and the first step, the researchers used the keywords and
unknown. Moreover, this paper has addressed the their synonyms. The other strategy used was using the
research question of the factors affecting post-­ “OR” logical operator in the database search engine.
disaster temporary housing construction and the The keywords for this search were as follows: (sus-
relation between them. Finally, this study provides a tainable development OR sustainable OR [resilience
comprehensive review of previous research that has or resiliency or resilient]) and (Temporary Shelter OR
examined the combination of these factors that affect Temporary housing OR post-disaster shelter).
the temporary housing process.
In the next step, these two searches were searched
POST-DISASTER CONSTRUCTION using the “AND” logical operator to find the docu-
ments containing both terms: (sustainable develop-
More than conventional construction projects, ment OR sustainable OR [resilience or resiliency or
post-disaster construction deals with issues such resilient]) AND (Temporary Shelter OR Temporary
as time constraints,18,19 price fluctuation and infla- housing OR post-disaster shelter).
tions,20 debris and waste management,21 and resource
availability.22,23 This makes the temporary housing in Throughout this search, the researchers applied
post-disaster more restricted and challenging. These the selected filters to narrow the scope and get the
houses are “temporary” and are only meant for a spe- desired result. The fitters used for this research were
cific short period that needs to be considered. Creating as follows:
transitional houses requires a significant amount of
diligence and dexterity. They need to meet the compli- nnThe researchers did not consider war, ter-
cated and broad range of affected people’s needs24 in a rorist attacks, and human-made catastro-
challenging type of environment.20 Building based on phes such as nuclear meltdown as a scope
people’s needs and meeting their needs are considered of this project.
the top priority and core idea in this kind of construc-
tion. This factor is highly subjective and changes nnThis research focused on the short-term
depending on numerous factors such as the magnitude recovery process in post-disaster recon-
and type of disaster,14,23 location, logistics, and com- struction and not emergency shelters or
munity characteristics such as culture, population, permanent housing.
density, and climate conditions of the region.15
nnThis research studied any articles or docu-
STUDY APPROACH ments published within the last 20 years
(1999-2019).
For this study, the researchers employed an inte-
grated systematic search flow method and a biblio- Figure 1 shows the roadmap of this stage of the
graphic review method. The first step was to determine literature review process. Two hundred sixteen docu-
the general factors that can lead to creating a resilient ments from the Academic Search Premier and 347 doc-
temporary house. For this mean, the researchers uments from Engineering village were extracted from
used “Academic Search Premier” and “Engineering this search. Next, the researchers cross-checked the
Village” as databases, which were accessed through documents to exclude any duplicate findings through
the Purdue library portal in order to conduct this

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Figure 1.  Roadmap of the literature review (Part A).

an in-depth manual investigation. The findings were a I. Shipping: transportation, resource
list of numerous factors that can affect the temporary availability, time, vehicle availability,
housing from the construction point of view; the results road condition, traffic, and material type
were then divided into the following categories: and size.

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II. Environmental impact: durability, life bias of selected articles, (b) the wrong definition of
cycle, recyclability, after life, site pollution, the queries, (c) logical operators that are not applied
and transportation. elaborately, and (d) alerts that are solely used for
periodicals.
III. Community characteristics: climate,
customization, privacy, safety, population TEMPORARY HOUSING CONSTRUCTION CRITERIA
density, cultural appropriateness, and
a­ esthetics. In the following section, this article investigates
each of the selection criteria for the temporary hous-
IV. Labor workforce dependency: instal- ing type.
lation, speed, safety, workforce training,
psychology, working hours, and weather Shipping
conditions. Post-disaster temporary housing construction can

V. Vulnerable population: seniority, ethnic- be categorized into two major groups. The first is off-
ity, minority, mental illness, poverty, and site construction, where most of all the construction
illness. process is done in an indoor factory environment,
away from the actual site, and then shipped to the
VI. Logistics: land availability, number of site for assembling.15 The second group is onsite con-
evacuees, city density, and accessibility. struction or the traditional “stick” method, where the
raw materials are shipped to the site, and temporary
VII. Living condition: health risk, ther- houses are built by labor on site. According to many
mal insulation, air quality, material, and researchers,25,26 this criterion can be recapped as the
­structural. type of the transportation system and the number of
shipments needed for creating the temporary houses.
In the next step, the researchers applied the same Another issue with the shipping process is the late
method to review the literature regarding each factor delivery, which can delay the whole temporary hous-
and describe how they affect the housing construc- ing process.
tion procedure. They used each factor like keywords
and applied them separately to the database, repeat- Discussion. While some researchers believe that the
ing the same process shown in Figure 2. The process best strategy to have fast sheltering is to use onsite
was repeated eight times, wherein each scenario was materials in a natural disaster, many local material
changed with keyword #2, while keyword #1 was the suppliers might be damaged or unable to function
same in all the iterations. The list of keywords is in such events.27-29 Therefore, it is required in many
shown in Table 1. scenarios to import the commodities needed for creat-
ing shelters for the region. When using offsite tempo-
The findings were then again filtered based on rary housings, this factor will depend on factors such
this research’s scope and then sorted so that duplicate as the distance of the manufactory, vehicle, driver
results would be opted out from the studies. There availability, and fuel price.30 Offsite accommodations
are several advantages in the used method, many of are more dependent on transportation. Therefore,
which can considerably benefit the research work. In transportation systems such as roads, airfields, and
this concern, the method defines precisely the steps rails and how much they have been damaged play
to be taken to process and analyze the data. It also a vital role.20 As the scope of a natural disaster
applies multi-tier filters and alerts that augment the increases, the need for reconstruction grows exponen-
method’s functionality and performance. On the other tially, leading to high demand for construction mate-
hand, the limitations of the method include (a) the rials and labor in the market.31 This sudden demand
results in a price surge of these services, even up to

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Figure 2.  Roadmap of the literature review (Part B).

nearly 50 percent in some cases. According to a case the elements determining the cost of the units. Based
published by the Federal Emergency Management on the magnitude of the disaster and the amount of
Agency and International Federation of Red Cross destruction, the site’s access might be compromised
and Red Crescent Societies,23,32 transporting materi- and, therefore, not be easily reached.29,34-37 Besides,
als and hiring labor can cost as much as the tempo- long traffic lines are expected as many responses, and
rary housing itself in some areas. aid vehicles will drive to the affected region.38

Also, transporting these units needs careful plan- Environmental impact
ning and specific cargo and trucks. Blocked or dam- Debris and waste management are critical issues
aged routes of travel more restrict the larger assem-
bled modules, and the vehicles and trailers that can in post-disaster situations as a considerable amount
move these larger factory-built assemblies are fewer in of building waste is generated in a short period. Like
number.33 The vehicles and trailers that can move the any other construction task, creating temporary
larger factory-built assemblies are fewer in number. houses can generate a considerable amount of mate-
Therefore, transportation can be considered as one of rial waste, mostly built on site and not in a factory

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Table 1. List of keywords used in the search engine

Number Keywords Includes
Keyword #1
Temporary housing (temporary shelter OR temporary housing OR post-disaster shelter)
Keyword #2
Sustainable (sustainable development OR sustainable OR (resilience or resiliency or
Keyword #3 resilient))
Keyword #4
Keyword #5 Shipping (transportation OR shipping OR moving)
Keyword #6
Keyword #7 Environmental impacts (environmental impacts OR durability OR recycle)
Keyword #8
Keyword #9 Community characteristics (community participation OR culture OR community driven)
Keyword #10
Labor workforce dependency (labor workforce OR installation OR equipment installation)

Vulnerable population (vulnerable people OR vulnerable OR stressed)

Logistics (site OR land use OR logistics)

Construction cost (construction cost OR affordable OR life cycle cost)

Living conditions (living conditions OR thermal comfort OR wellness)

and shipped to the site. In addition to material discuss how the environmental impact can be meas-
waste, as mentioned previously, resource availabil- ured based on the criteria such as the amount of
ity is another issue that the contractors deal with material waste, noise, and dust pollution generated
in making post-disaster housing. Suppose that the during the shelter construction.
stakeholders choose to use nonlocal materials. In
that case, it is imperative to consider the weight and The afterlife phase of the project is another part
size of the material and the number of trips needed of the environmental impact. Prefabricate kits have
for bringing the materials.39 Trucks bringing materi- more degrees of freedom in terms of usage after the
als emit CO2, thus playing a role in the environmen- disaster. As Félix, et al.44 discussed, they can either be
tal impact. dismantled, reused, sold, demolished, or be purchased
by occupants for long term use. However, in terms of
Unlike typical construction projects, temporary traditional onsite houses, this is not the case; many
houses are only meant for a specific short time. researchers, such as Arslan45 discussed that it is ideal
Therefore, the life cycle of units after their intended to reuse salvaged materials from affected houses
use is of vital importance. While these accommodations for constructing new temporary lodgings. Moreover,
are initially created to accommodate between 5 and 24 it helps with the debris and waste management of
months, people might end up living in them even up the region, but it can reduce the units’ overall cost
to 5 years.40 This gap in the intended timeframe and noticeably. However, reusing the salvaged materi-
actual timeframe of the usage can lead to numerous als requires a strict and thorough evaluation and
maintenance issues; thus, some researchers, such as inspection of potentially hazardous substances in the
Idemen et al.41 use lifetime performance as a criterion old debris.46 Materials excavated from flooded areas
for evaluating temporary houses. should go through additional screening as they could
be contaminated from the stagnant water.47 This
Discussion. Constructing a temporary house can inspection process needs experts in the field with
have many indirect consequences of environmental adequate equipment, making the process costly and
impacts, such as greenhouse emissions and the pro- adding to its first-proposed time frame. Increasing the
cess’s energy consumption. Many researchers30,42,43 lifecycle of the temporary houses not only protracts

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the overall time of the project but also increases the cultural needs, user acceptance, and satisfaction to
cost significantly.32 the region by participating in the temporary hous-
ing process. Many researchers have accentuated the
Community characteristics importance of community participation towards sus-
The community can be defined as “individuals tainable development of the region.54,55 The National
Disaster Housing Strategy report stated that, in
and groups sharing a natural and built environment order to reach a sustainable recovery, community and
that is vulnerable to hazards. In other words, the individuals need to be supported.56 The materials and
community is the general public: the users and occu- architectural style of the temporary houses must be
pants of the built environment and the beneficiaries acceptable to the victims or wish not to stay in the
of post-disaster reconstruction.”48,25 The temporary units. Despite their importance, many issues have
house users are the affected community; therefore, not been addressed adequately in current post-disas-
it is essential to design these spaces germane to ter temporary housing practices.57 The “Community
their characteristics. Creating accommodations that Characteristic” measure needs to consider climate,
ignore the cultural characteristics and the lifestyle culture, and the vulnerable group of the inhabitants
of the specific region can bring dissatisfaction to the and the regions’ density and population.17,43,50,58
local users.49 As Bashawri et al.17 has discussed, each
region and community can have its design style and Labor force dependency
form for a building based on the specific culture of Labor forces on site are considered an integral
the region and are responsive to that area’s climate.
The sustainable performance elements have been part of the temporary housing construction process.
defined, such as user acceptance and satisfaction of Recruiting skilled labor in an affected area in a short
the temporary houses and the aesthetic and beauty amount of time can be challenging as a large scale of
of the building as social criteria.50 These criteria are construction needs to be done in a short period with
not static but are susceptible to changes based on the a limited amount of skilled labor.59,60 Contractors can
location, time, and generations.51 field a team of expert trainers to impart essential
construction technical skills and knowledge to create
Climate conditions, population density, and urban temporary houses for local people. This can reduce
patterns are essential for each community when cre- overall housing reconstruction times by generating
ating temporary houses. As the population grows, the higher productivity with better work quality.28 The
number of people living in cities increases, and there- utilization of local knowledge and labor can create
fore, high rise and multi-story buildings become more microeconomics to aid the recovery process.61
prevalent.15,52 As time progresses, the social formation
of families and household changes, as the Institute of Discussion. While manufactured homes are the most
Medicine and the National Research Council states, prevalent type of temporary housing in developed
changes in the family configuration and immigration, countries such as the United States, the most under-
age distribution, and people’s expectations have dras- developed countries still use traditional onsite tem-
tically changed the traditional household formation porary housing in a disaster. Using the labor work-
and social patterns.53 These rapid and spikes in social force in post-disaster reconstruction is considered a
patterns lead to a broad spectrum of needs, build- challenging factor. In this case, when the company in
ing numerous modules, and options that fit all these charge of creating temporary houses to bring its crew
needs and local issues.44 on site, housing the workers itself would itself become
an issue.62 How the workforce and people from the
Discussion. Unlike other factors discussed in this community participate in the construction process
paper, community characteristics are considered a has been investigated and found useful.52 However,
subjective factor that cannot be measured using this brings a group of experts and novice to a specific
conventional systems. The community can apply the

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kind of job site, which makes the process vulnerable checklist contains numerous safety topics: general
to three kinds of issues: safety, electrical safety, preventing and treating ill-
ness and diseases, and cleaning up after emergency.69
1. Human errors: The labor training is defined as a work process that
needs to be performed where the labor workforce
Human errors are an inevitable part of workforce is being used.28 This training not only is limited to
dependency in the post-disaster situation due to the teaching the workforce to build but also covers a
extreme conditions of the situation.19,27 Different broad range of safety topics such as chemical and
variables such as lack of skill, working conditions, biohazard, physical hazards, and equipment hazard
weather conditions, lack of coordination between dif- training.70 Therefore, the managers need to invest in
ferent groups, and time limitation affected labor pro- time and cost to ensure that the construction team
ductivity in construction.63-65 Depending on the scale has proper safety training before starting the process.
of the disaster and the affected region’s population,
the number of temporary houses assigned to be built A post-disaster area can be considered a danger-
at any location will vary. Because of this, contractors ous place for the cleanup and reconstruction crew.
typically have numerous construction teams working Often, many structures have fallen, and the struc-
simultaneously in order to save time. tural integrity of those remaining is most likely com-
promised. Therefore, the risk of people falling from
2. Safety: heights or part of a structure collapsing on them can
be high.19 Hot electrical power lines are considered a
In the condition of onsite temporary housing, significant hazard and deadly around water, as any
structures are assembled outdoors. The laborers contact can lead to a fatal electric shock.71 Broken
are installing and constructing them vulnerable to water and gas pipes are another typical results after
weather conditions. Excessive cold, extreme heat, such disasters. Therefore, anyone working in this sit-
wind velocity, air quality, noise, and humidity are uation must take extreme caution.47 Stagnant water
some of the factors that degrade labor performance.66 can be a source of many infectious diseases, as well as
Both cold and hot temperatures can be dangerous many respiratory health issues. Even if the source is
for the workers if they need to work outside for a potable, all water flown over open ground should be
long time.67 Staying in an outdoor environment for treated as blackwater carrying dangerous pathogens.
an extended period in wind chill temperatures can People on the site must then wear proper equipment
lead to fatigue, hypothermia, frostbites, and even such as protective gloves and goggles, masks, and
death. According to the US Occupational Safety and water-resistant uniforms.70
Health Administration (OSHA), employers should
train workers for such conditions and provide them 3. Speed:
with protective clothing and equipment. Even in that
case, employers should reschedule the construction In a construction project, the project manager
for warmer days, but that alternative may be imprac- schedules the timeline based on its scale and the
tical in post-disaster housing.68 Similar precautions deadlines. While the number of crews and workers in
apply for hot temperature conditions, where employ- the site might vary, the schedule does typically not
ers need to train workers and provide shades and sup- exceed 8 hours per day, 5 days a week. However, in
plies such as water bottles and monitor the workers’ post-disaster situations, conditions are very differ-
wellbeing. ent. Speed is crucial in these scenarios as the victims
need to be secured in temporary houses as soon as
The Center for Diseases Control and Prevention possible. Although time is critical, the quality of these
(CDC) has issued a safety checklist for performing temporary units also matters. The keen demand for
cleanup and reconstruction in the disaster zone. This “more, better, faster” production intensifies. Part of

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the solution is working more hours per day—perhaps directly impact the health, mental, and physical of the
extending the effort to 12 hours a day, seven days a vulnerable population.80 As the assembling process
week.19 From before, unlike a regular construction of these types of accommodations is considered time-
project, the team working in a post-disaster situa- consuming, people tend to find other places to go or
tion maybe a medley of labor, hired by contractors or live and give up on the idea of returning.81 In this sce-
comprised of volunteers, the latter of whom commonly nario, people who lived in more vulnerable areas are
lack required expertise. The stress and pressure of more likely to leave the affected area. This can result
finishing the work in a limited time in extreme con- in socioeconomic upset not for the affected region but
ditions and shortage of skilled labor are considered also the neighboring regions as well. Therefore, how
factors that can cause fatigue and ineffectiveness in the reconstruction process is planned and executed
the long term in the active personnel and laborers.72 has a vital role in the long-term sustainability and
This issue can subsequently lead to an inferior final livelihood of the vulnerable people within the needy
product characterized by a lasting drag on the victims community.82,83 Currently, no adequate supervision
and the community. and attention to the needs of vulnerable and disabled
people are in place. The poverty level has no statisti-
Vulnerable population cal significance as a factor for planning post-disaster
The vulnerability can be defined as struggling housing by agencies such as the Federal Emergency
Management Agency (FEMA).84
with anticipating, coping, resisting, and recovering
from the impact of the disaster.73 Therefore, vulner- Logistics
able people’s needs require extra attention to be After a disaster, all activities regarding creating
adequately addressed. The vulnerable population
can be divided based on different factors such as age, temporary housing must assess and address land
socioeconomic status, gender, race, and ethnicity, liv- issues, which will vary by disaster and context.85,86
ing in densely populated areas, medical issues, and Land issues influence the recovery speed from a dis-
disability.71,74,75 For displaced populations, the disrup- aster and significantly influence a transitional hous-
tive effects may continue for years as they struggle ing strategy. This issue can be looked at from different
to return to affected areas.76 The quality of recovery perspectives such as land availability, land ownership,
has a decisive role in low-income families’ conditions the number of evacuees, infrastructure availability,
as overlooking this factor might result in “selective ease of transportation, accessibility, topography, and
return migration.“77 Today’s society consists of a mix- safe access.87-92
ture of people from different races and even different
languages. A diverse, multilingual nature that is a Accessibility is another issue that needs to be
vibrant multiculturalism source can also be a source considered for selecting a location for creating post-
of vulnerability in post-disaster situations.78 disaster houses.93 Affected people need to be able to
have safe access to any public spaces while they are
Discussion. The needs of vulnerable people and how living in temporary houses. The population’s distance
temporary housing could impact the condition of vul- should be reachable, especially for the vulnerable pop-
nerable people are discussed.77 In addition to homes, ulation discussed earlier in the paper. Accessibility
vulnerable people require public services, such as applies for the people and is also a vital issue for mov-
schools and healthcare facilities.62 Keeping these ing equipment and resources and moving often heavy,
facilities in an acceptable quality is considered vital big equipment over a long distance with compromised
as a report by the National Coalition for the Homeless routes, which is considered a challenge.
reveals, and the school’s quality in New Orleans has
not yet returned to the pre-Katrina phase.79 The Discussion. Logistics is considered as a time-varying
standards and living conditions of temporary housing demand, which means that it is a function of time.86
This issue is connected with the population density

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and urban pattern discussed earlier in this paper. Discussion. After a natural disaster occurs, the area is
There is a need to address the identification of tem- prone to numerous infectious diseases.47 With the rise
porary housing sites (including supporting water, of population and density of the region, the incidence
sewer, electrical, and transportation infrastructure) of infectious diseases will increase.103 Therefore, in
as it can significantly impact the recovery process.56,94 order to keep the people safe from the excessive tem-
Land scarcity and the need for building multi-story, peratures or issues caused by the natural disaster
high-rise temporary housing are other issues that such as distilled water from broken pipes or floods,
need to be addressed, especially for developed cities. the types of transitional houses that are used in these
Many researchers have focused on developing optimi- areas are of vital importance in order to maintain the
zation models and decision-making tools to address health and safety of the people. Onsite temporary
temporary housing’s location issues. The models for housing can adversely affect the health condition of
managing the logistics for transitional housing can be the people on site. Building these accommodations in
either single objective models or multi-objective.89,95 place creates dust pollution and noise, causing harm
GIS modeling is yet another technique in the deci- to people’s health.104
sion-making process for selecting the location.87,96 A
bilevel location-allocation model for the flood evacua- DISCUSSION AND CONCLUSION
tion planning with shelter capacity constraints using
a genetic algorithm has been proposed and investi- This paper has profiled the leading indicators and
gated.97 In this model, the researchers have consid- factors that affect temporary housing construction
ered the location problem and the evacuee’s prefer- and has discussed each topic in detail. As mentioned
ence as two variables. However, some researchers previously in the research, numerous factors from dif-
have suggested that the temporary housing location ferent aspects affect the temporary housing process.
stems from numerous factors such as cultural char- This research’s scope and focus are specifically on the
acters, privacy, and accessibility.97 Other researchers factors that affect the temporary housing construction
discuss that temporary lodgings’ location needs to be method and not the organizational and managerial
sheltered close to their original houses to improve and part of the process. Table 2 summarizes researchers’
strengthen their emotional and social issues.98 Based studies over the two decades, which have studied
on the type of families and individuals and their various factors from different disciplines in their
needs, these temporary spaces need to have access to research. As shown in the table, the “community char-
public spaces and services such as hospitals, schools, acteristics” and “environmental impact” are the most
and kindergarten. Even grading units are based on dominant factors, which have been repeated. Table 3
the ease of access to public transport. depicts the total number of studies on each discipline
and factor. This total comes from the research and
Living condition gray literature in the last two decades. These data
Thermal insulation, health risks, and air qual- are driven by the articles that solely studied the
topics and articles that studied the factors together.
ity are considered as main topics regarding living According to this analysis, the top three factors affect-
conditions. When a disaster strikes, keeping the ing the post-disaster temporary housing construction
occupants protected from extreme weather condi- are the community characteristics (24 percent), envi-
tions and health risks is one issue that needs to be ronmental impact (18.8 percent), and “affordability”
addressed.99 Besides, creating an environment that (17 percent). According to this table, the same trend
promotes the occupants’ wellbeing is the next step of Table 2 follows where the environmental impact,
that needs to be addressed. Some of the issues that community characteristics, and affordability issues
need to be addressed are air circulation,100,101 volatile are the three most frequent issues studied in the arti-
organic compounds,90 mold presence,100 and acoustical cles. The rank of factors according to the frequency of
comfort.102 citation is shown in Table 4.

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Table 2. Studies on the group of factors effecting temporary
housing in the post-disaster situation

Factor Author Afford- Community Environmental Labor Logistics Quality and Shipping Vulnerable
ability Characteristics Impacts W­ orkforce Health people

FEMA23 X x

Nath et al.16 xX x xx

Johnson105 x x

Escamilla and Habert30 Xx

Chang et al.20 x

International F­ ederation X x x
of Red Cross and Red
­Crescent Societies32

Karunasena and xx
R­ ameezdeen106

Zhang et al.61 xx

Félix et al.44 xx x x

Perrucci et al.107 xx x

Arslan45 xx x

Ford et al.15 xx x x

McIntosh108 xx

S¸ ener and Torus43 x x x x

Abulnour27 xx xx x

Torus and S¸ ener109 xx

Lopez and Froese26 xx

Preston and Bank110 xx

Maly and Iwata111 x

Nemati et al.112 x x x

Ryan et al.113 xx

Hui and Ming33 x xx

Potangaroa114 xx xx

Szubryt-Obrycka115 x x

El-Anwar et al.5 xx x

Kim and Kim116 xx

Supadli et al.117 xx

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Table 2. Studies on the group of factors effecting temporary
housing in the post-disaster situation (continued)

Factor Author Afford- Community Environmental Labor Logistics Quality and Shipping Vulnerable
ability Characteristics Impacts ­Workforce Health people

Rohwerder118 xx xx

Bilau et al.63 x xx

Bashawri et al.17 xx xx x

Xi119 x x x

Jachimowicz84 xx xx

Bevington et al.120 x xx

Bartusiak and Said121 x xx

Nappi and Souza91 x xx

Rakes et al.62 x xx

Murray52 x xX

Kongsomsaksakul et al.97 x x x

Farmer et al.122 xx x

Hu et al.123 x x

Table 3. Frequency of the sources Table 4. Factors affecting temporary housing
studying each factor
Rank Factors

Factor Number of Sources 1 Community characteristic

Shipping 70 2 Environmental impacts

Environmental impacts 94 3 Shipping

Community characteristics 120 4 Living conditions

Labor workforce dependency 35 5 Logistics

Vulnerable population 22 6 Labor workforce dependency

Logistics 36 7 Vulnerable population

Living conditions 38

The factors listed in the previous section can be approach” section. As seen in this figure, the two
categorized into two major sections: physical and factors are not entirely separated from each other,
social. Figure 3 shows the categorization of this sys- affecting each other. For example, based on the litera-
tem. For better visualization, the researchers have ture, “logistic,” which is a physical factor, is affected
used the coding of subfactors, noted in the “study by the “population density,” which is a subset of the

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90 Journal of Emergency Management
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Figure 3.  Flow and relations of the factors.

community characteristic factor, which is considered charge of long-term housing can use the information.
as a social factor. Therefore, the type of units and the This would help define the variables and restrictions
materials used for the temporary houses, which lead affecting the whole process, which can help define and
to the shipping type, are also affected by population create a multi-objective optimization framework.
density, where this factor decides the type of tempo-
rary house. Mahdi Afkhamiaghda, PhD candidate, Department of Computer
Graphics Technology, Purdue University, West Lafayette, Indiana.
As time passes, the population grows, and urban
and city patterns change. Different needs will form in Emad Elwakil, PhD, PE, CCE, PMP, School of Construction Management,
the event of a natural disaster. Not only reaching the Purdue University, West Lafayette, Indiana.
optimal value for all factors is impossible, but also
some factors can be conflicting with each other. This Kereshmeh Afsari, PhD, Assistant Professor, Myers-Lawson School of
results in an even more complex system. Different Construction, Virginia Tech. University, Blacksburg, Virginia.
tasks and work processes are linked together to form
the whole process.91,124 Factors are interconnected and Randy Rapp, DMgt, PE, CCP, Associate Professor, Construction
affect each other, deciding each other’s practicality, Management Technology, Purdue University, West Lafayette, Indiana.
also known as the “controlling element.”
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JEM Vulnerable populations: A cross-case synthesis of
correctional facility disaster response during
Hurricanes Katrina and Maria

Carl Dement, BA (Hons), MA
Tony McAleavy, BA (Hons), MSc, PhD

ABSTRACT support measures for the Bureau of Prisons (BOP)
and state institutions by involving the FEMA and the
Objective: This study aims to critically evalu- Government Accountability Office (GAO). The other
ate the Orleans Parish Prison (OPP), New Orleans, four are recommended improvements in EM planning
Louisiana response to Hurricane Katrina in 2005 and for counties and municipalities.
the Metropolitan Detention Center (MDC), Guaynabo,
Puerto Rico, response to Hurricane Maria in 2017 to Key words: prison emergencies, disaster planning,
determine key areas for policy development. vulnerable populations, hurricane Katrina, hurricane
Maria
Design: This study uses an interpretivist para-
digm to conduct an inductive, cross-case synthesis and INTRODUCTION
content analysis.
The decision to evacuate in the face of a severe
Setting: The OPP in Katrina and the MDC in hurricane threat is a difficult and multifaceted one.
Maria; case-studies determined by similar exposure to Forecasting the track of hurricanes is problematic given
hurricanes in the Caribbean and inmate population. their tendency to change direction, speed, and strength
unpredictably.1 Politically speaking, hurricane evacua-
Subjects:  Inmates as an intrinsically vulnerable tion decisions are a lose-lose scenario. Decision-makers
population. who mandate an early evacuation but whose com-
munities are not impacted face backlash for unneces-
Interventions: Cross-case synthesis of the two sary movement, disruption, and expenditure.2 However,
selected case-studies comparing response to separate those who do not order an evacuation, or wait too long,
hurricanes. are blamed for the resulting injuries and loss of life. For
example, Governor Kathleen Blanco and Mayor Ray
Main outcome measure(s): The ProQuest, Nagin were resolutely criticized for delaying the order
Wiley, Scopus, Science Direct, and Google Scholar to evacuate New Orleans in the aftermath of Hurricane
databases were used to establish a corpus of qualita- Katrina in 2005.3 Similarly, Houston Mayor Sylvester
tive data focused on the evacuation and humane treat- Turner was both praised and criticized for not ordering
ment of inmates. Inductive content analysis resulted in a mandatory evacuation in the face of Hurricane Harvey
three themes which informed seven policy recommen- in 2017 highlighting the dilemma such decisions pose.4
dations for enhanced correctional facility prepared-
ness for natural and human-induced hazards. Those most vulnerable to the hazards of a hur-
ricane are also those least able to facilitate an evacua-
Results: The preparedness of correctional facili- tion when necessary.5,6 Risk exposure and the inability
ties remains inadequate despite significant experience of vulnerable populations to mitigate or prepare for
during Katrina, Maria, and other disasters demon- known hazards is a key feature of the literature.6-11
strating a failure in isomorphic learning.

Conclusions: The theoretical contributions of
this study are encapsulated in seven recommenda-
tions. Three are recommended accountability and

DOI:10.5055/jem.0633 Special Issue on Puerto Rico
Journal of Emergency Management
Vol. 19, No. 8 97

These same studies have identified poverty, race, age, segments of the population are less able to withstand
immobility, and gender as characteristics of the socially the adverse impacts of both natural and human-
vulnerable. Yet incarcerated persons, inmates herein, induced hazards.19 The vulnerability of these groups
who are among the most vulnerable of populations, to the effects of hazards implies a governmental duty
are frequently ignored in this vital discourse. By any of care; this obligation to aid those who cannot help
definition presented, inmates are readily identifiable themselves extends to all levels of government.
as vulnerable persons. In spite of this, they are seldom
mentioned in the vulnerability literature, and perhaps Within the paradigm of disaster management,
more importantly, are rarely considered by emergency vulnerability is assigned to those most at risk of
planners.12-14 Correctional facilities house inmates who harm from either natural or human-induced hazards.
are typically ignored in all phases of disaster manage- The poor, minorities, the elderly, women, and recent
ment: mitigation, preparedness, response, and recov- or transient residents are traditionally considered
ery. However, civil society has a clear duty to protect vulnerable groups.20 Vulnerable populations often
this group despite their crimes; inmates need to be pro- lack coping capacity; a defining characteristic of these
tected as much as any other vulnerable population.15-17 groups is their inability to cope when disaster strikes.
Inmates share many of the characteristics that tradi-
Inmates are members of society who are deprived tionally distinguish vulnerable groups.21 Regardless
of their liberty while serving time in a prison or a jail, of adjudication level, both the movement and deci-
or a patient confined to a medical facility for treat- sions of inmates are severely restricted meaning they
ment.18 By definition, they lack freedom of movement lack coping capacity and are among the most vulner-
as most aspects of their daily lives are controlled able to disasters. Consequently, inmates are unable
and directed by the jurisdiction to which they are to prepare for a disaster and cannot respond when it
remanded ensuring they are among the most vulnera- strikes. They are entirely reliant on their custodians
ble of populations. This is especially so during times of for support and protection.
disaster. Recent correctional facility preparedness ini-
tiatives have been inadequate and require significant Planning and exercises of all types and at all
improvement to adequately fulfill this important, but relevant organizational and government levels must
sometimes overlooked, duty of care. Accordingly, this include the correctional community. In the years since
study aims to critically evaluate the Orleans Parish Katrina, numerous examples of correctional facilities
Prison (OPP), New Orleans, Louisiana response to either having no emergency plan, an inadequate plan,
Hurricane Katrina in 2005 and the Metropolitan or failing to implement a plan, have come to light. An
Detention Center (MDC), Guaynabo, Puerto Rico, example of inadequate preparations for emergencies in
response to Hurricane Maria in 2017 to determine key a correctional facility came as recently as January 27,
areas for policy development. Although separated by 2019 when a power outage at the MDC—Brooklyn left
12 years and 1,703 miles, the planning and response inmates in freezing conditions for a week.22,23 Similarly,
failures, and disturbing accounts of inhumane living the abandonment of inmates to inhumane conditions
conditions, during these hurricanes are glaringly simi- occurred in Hurricanes Rita, Ike, Harvey, and Irma.14
lar providing the basis for comparative analysis. Timely evacuation before a hurricane makes landfall is
one of the most successful coping tools available to pop-
LITERATURE REVIEW ulations within a known hurricane hazard zone. The
nature of hurricanes provides ample opportunity for
Subgroups without a political voice can be found warnings and protective action decisions.1 The general
in societies around the world because of one or more public, ie, the nonincarcerated, can readily access this
characteristics. These groups are more vulnerable to information and other informal hurricane warnings.
disasters because they lack the political power and In addition to official warnings and evacuation orders,
means to protect themselves.9,10 Social vulnerability microblogging and social cues are available.24 However,
theory attempts to explain how and why various vulnerable groups, such as inmates, do not have this

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98 Journal of Emergency Management
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