In the wake of the 2017 Dual Hurricanes (i.e., IRMA and MARIA) and the tremendous impact on the Commonwealth of Puerto Rico, Drs. Pietro Marghella (D.Sc.) and Leonard Singer (M.D.) were deployed to support the Governor and the Secretary of Health to develop a comprehensive response and recovery plan for the Commonwealth’s medical and public health critical infrastructure sector. Both had extensive experience in national-level medical planning addressing strategic-impact threats, including having served as principal authors for the National Smallpox Response Plan (2002); the National Catastrophic Incident Response Plan for the response to acts of domestic nuclear terrorism (2004); the CDC’s first-ever National Operations Plan for Pandemic Influenza (2006); and the Federal Implementation Plan for Pandemic Influenza in response to 2009-10 H1N1 Pandemic.
For all intents and purposes, Hurricane MARIA—the latter of the two hurricanes and by far the worst in terms of impact—was a black swan event overlying a long-standing wicked problem. Puerto Rico suffered nothing short of catastrophic damage. Puerto Rico had long been victim to a severe economic downturn. The impact of the storms exacerbated an already tenuous situation, propelling a series of confluent, cascading events throughout the island’s interdependent critical infrastructure. The hurricanes caused a total breakdown of the electrical grid. Telephone and satellite communications supporting the cellular nets were shattered. A good proportion of the island’s potable water supply had been compromised. Fuel and available transportation were severely limited in some locales. Of the 69 hospitals on the island, only 11 were considered functional in the immediate wake of the hurricanes, severely limiting services for those injured by the storms and exacerbating the conditions of those suffering from chronic illness and disease. The extremely high number of chronic patients among the population were at significantly greater risk of morbidity and mortality because of lack of medicine, lack of access to functioning hospitals, and lack of transport. In the immediate aftermath of the storms, it was impossible to estimate the levels of mortality that would be attributed to these secondary levels of disaster. Total losses in the Commonwealth from the hurricane are estimated at up to $95 billion, making the cost of the disaster comparable to that of previous Hurricanes IRMA and HARVEY combined. While the recovery of Hurricane KATRINA continues now after more than 14 years, Puerto Rico’s isolation as an island territory of the U.S. may significantly increase that time. A rapid response and recovery of Puerto Rico’s healthcare and public health infrastructure was by far the most pressing issue facing Commonwealth and federal authorities since saving lives and reducing suffering is the single most important priority of the incident management mission.
As a result of Marghella and Singer’s analysis of the broad picture of healthcare capacity and capability at 4-6 weeks post MARIA landfall, it was their conclusion that the primary healthcare deficits after the storm were not the classic “staff, stuff and beds”, but were instead infrastructure needs, i.e., power, water, fuel, Internet, communications, and transportation. A robust and detailed plan for decentralization and regionalization of the island’s healthcare assets was presented to Governor Rosallo and the Department of Health of Puerto Rico. This plan was later presented to members of Congress in Puerto Rico’s attempt to obtain recovery funding. Additionally, members of the National Security Council at the White House requested a private briefing on its contents. It is expected that this plan may have significant influence on healthcare policy on the mainland in all-hazards planning.