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September 27, 2017

'Like in war': Puerto Rico faces mounting health crisis after Hurricane Maria

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    HHS Secretary Tom Price last week declared public health emergencies in Puerto Rico and the U.S. Virgin Islands as medical providers in those areas struggle to recover from Hurricane Maria.

    Less than two weeks after the island was hit by Hurricane Irma, Hurricane Maria, a powerful Category 4 storm, tore through Puerto Rico on Sept. 20 with 140 mph winds, Vox reports. According to Vox, Hurricane Maria is the fifth-strongest hurricane on record to hit the United States.

    When a disaster occurs, the whole hospital is our patient

    Jeff Weber, a meteorologist with the National Center for Atmospheric Research, said Hurricane Maria "was as if a 50- to 60-mile-wide tornado raged across Puerto Rico, like a buzz saw," adding, "It's almost as strong as a hurricane can get in a direct hit."

    The storm knocked out power across Puerto Rico, and nearly a week later, most of the island's 3.4 million residents are still without power. As of Tuesday, FEMA reported that only 11 of Puerto Rico's 69 hospitals had power or a fuel supply. According to the New York Times, it could take four to six months to fully restore power to the island.

    The storm also has affected the island's water supply. As of Tuesday, 44 percent of residents lacked access to potable water, Vox reports. According to Reuters, at least 10 people have died from the storm.

    Maria's damage

    As a result of the damage, the majority of Puerto Rico hospitals have closed, and those that remain open are grappling with infrastructure damage, fuel shortages, and a spike in patients seeking emergency care, the Times reports. Puerto Rico Gov. Ricardo Rosselló (NPP) on Tuesday said getting all of the island's hospitals working is a top priority, and has called on federal lawmakers to approve additional aid to address the "unprecedented disaster."

    According to the Wall Street Journal, many hospitals have canceled elective surgeries. The Times reports that dialysis patients on the island are getting care, and seven regional hub hospitals are accepting patients.

    Puerto Rico's main public hospital, Centro Medico in San Juan, is open, but Jorge Matta González, the hospital's executive director of medical services, said the power continues to go on and off, forcing staff to switch to generators that require constant refueling. Two of the hospital's 24 operating rooms are working, and providers in the emergency room are treating more than 160 patients per day.

    "This is like in war: You work with what you have," said Carlos Gómez-Marcial, Centro Medico's ED director.

    Victor Ramos Otero, president of the College of Doctors and Surgeons of Puerto Rico, said hospitals and open pharmacies—of which there are few—have adequate supplies for now, but there are concerns that suppliers will not be able to reach them to restock. A CVS spokesperson said that as of Tuesday, 21 of the company's 25 Puerto Rico-based stores were open, and a Walgreens spokesperson said about half of its 120 stores were open and receiving supplies.

    Officials expect that the status of Puerto Rico's health system will decline further as more hospitals lose the ability to use generators, Reuters reports. Michael Garner—regional coordinator of HHS' disaster medical assistance team, which is working to establish temporary hospital units at Centro Medico—said, "I think this might be a calm before we see an influx as other hospitals lose generators." He added that Puerto Rico's lack of communications, fragile infrastructure, and remote location are intensifying the island's logistical challenges to recovering from the storm.

    Read our interview with Warner Thomas about rebuilding after Hurricane Katrina

    Hospital response

    Medical evacuees from Puerto Rico began arriving in Shreveport, Louisiana, and Columbia, South Carolina, on Sunday, where they are being transferred to local hospitals for care through the National Disaster Medical System, which the Department of Defense now has implemented for the first time, WISTV reports.

    Patrick Card, area emergency manager for Veterans Health Administration's Office of Emergency Management, said evacuated patients "are placed onto an aircraft flown here, where we arrange for them to receive the definitive medical care they need within our community hospitals." He added, "We have what we call National Disaster Medical System partner hospitals who sign an agreement prior to a disaster, and those are the hospitals we primarily distribute the patients to during this type of event."

    According to The Atlantic, the U.S. government as of Tuesday had evacuated 150 patients from Puerto Rico and U.S. Virgin islands, and more are expected in coming days.

    Some providers are encouraging patients to evacuate. Ivan Gonzalez Cancel, a cardiovascular surgeon and director of Centro Cardiovascular's heart transplant program, estimated that he would not be able to perform open heart surgery for at least a month and said he has advised patients to travel to the continental United States for treatment. However, Gonzalez Cancel acknowledged that leaving the commonwealth also is difficult, as the island's main airport still is recovering from the storm.

    Public health concerns

    In addition to the immediate health crisis, public health officials are raising concerns about longer-term public health effects.

    The warm climate and flooding could fuel growth in the mosquito population, leading to an increase in mosquito-borne diseases, such as chikungunya, dengue, and the Zika virus. Further, the lack of access to clean water and food could lead to gastrointestinal outbreaks.

    Federal action

    In response to the hurricane, HHS has deployed federal disaster medical assistance teams from Arizona, California, Massachusetts, Oklahoma, South Carolina, and Texas. Federal officials also confirmed that the U.S. Navy will send its 1,000-bed hospital ship Comfort, which is equipped with 12 operating rooms and a pharmacy.

    HHS last week also modified or waived certain CHIP, Medicaid, and Medicare requirements to help residents of the territories access needed health care services and items.

    For instance, HHS temporarily waived or modified parts of the Social Security Act, including those that require "physicians or other health care professionals hold licenses in the state in which they provide services," as long as such individuals "have an equivalent license from another state" and are not "barred from practice in that state or any state a part of which is included in the emergency area." HHS also waived certain rules pertaining to directing, relocating, or transferring patients to other locations.

    In addition, HHS waived certain HIPAA penalties and sanctions for hospitals in Puerto Rico and the U.S. Virgin Islands. The limited waiver exempts hospitals in those areas from the HIPAA privacy rule's:

    • Requirement for hospitals to distribute a notice of their privacy practices;
    • Requirement for hospitals to honor a patient's request to opt out of a facility's directory; and
    • Requirement for hospitals to obtain a patient's consent to speak with the patient's family members or friends regarding the patient's care.

    The waiver also waives patients':

    • Right to request confidential communications; and
    • Right to request hospitals' privacy restrictions.

    Sen. John McCain (R-Ariz.) and at least eight House lawmakers have also called on the Department of Homeland Security (DHS) to waive the Jones Act, which places restrictions on foreign shipments. McCain wrote, "It is unacceptable to force the people of Puerto Rico to pay at least twice as much for food, clean drinking water, supplies and infrastructure due to Jones Act requirements as they work to recover from this disaster." DHS has declined to waive the Act, arguing that there is a "sufficient capacity" of U.S.-flagged vessels.

    Meanwhile, FDA Commissioner Scott Gottlieb on Monday said the agency would work to address drug shortages that could stem from damage to drugmakers based in Puerto Rico, Politico's "Pulse" reports.

    Gottlieb acknowledged that the United States could "soon face critical shortages if we don't find a path for removal or ways to get production back up and running."

    According to "Pulse," Gottlieb has ordered FDA to develop a hurricane shortage task force to mitigate the crisis. Gottlieb added that federal agencies also are working to address issues related to refrigerating, storing, and transporting medical products amid the damage (AHA News, 9/22; Respaut/Graham, Reuters, 9/24; Belluz, Vox, 9/25; Crawford, Shreveport Times, 9/25; Patrickis, WISTV, 9/25; HHS waiver, 9/19; CMS release, 9/21; Diamond, "Pulse," Politico, 9/26; Resnick, Vox, 9/260; Resnick, Vox, 9/22; Resnick/Barclay, Vox, 9/26; Robles et al., New York Times, 9/22; Ferre-Sadurni/Robles, New York Times, 9/26; Khazan, The Atlantic, 9/26; Hennessy-Fiske, Los Angeles Times, 9/26; McKay et al., Wall Street Journal, 9/26; Beavers, The Hill, 9/27; Gardner, Reuters, 9/27).

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