Sunday, July 15, 2018

Post-Disaster Sequelae


Three Major Disasters In Just Over 30 Days















#13,409


The NEJM has published a special report (see below) that attempts to calculate  the death toll in the wake of Hurricane Maria last September. As everyone knows by now, most of the inhabitants were without electricity, potable water, and cellular service for months.

Other long duration post-storm challenges included a badly damaged infrastructure and severely compromised supply chain, making it difficult to obtain food, prescription medicines, medical care, and police or rescue services. 
Extrapolating the results of a survey of 3299 randomly selected households, they estimated 4645 excess deaths occurred in first 100 days following the storm. 
I've excerpted the abstract, but you'll want to follow the link to read the report in its entirety.   After which, I'll have more.

Mortality in Puerto Rico after Hurricane Maria
Nishant Kishore, M.P.H., Domingo Marqués, Ph.D., Ayesha Mahmud, Ph.D., Mathew V. Kiang, M.P.H., Irmary Rodriguez, B.A., Arlan Fuller, J.D., M.A., Peggy Ebner, B.A., Cecilia Sorensen, M.D., Fabio Racy, M.D., Jay Lemery, M.D., Leslie Maas, M.H.S., Jennifer Leaning, M.D., S.M.H., Rafael A. Irizarry, Ph.D., Satchit Balsari, M.D., M.P.H., and Caroline O. Buckee, D.Phil.

Abstract 

 
Background

Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64.
Methods

Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016. 


Results

From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial.

Conclusions

This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.)
Not being a statistician, I'm not going to try to analyze their methods or results, I'll only toss in my 2 cents that this estimate is likely still an undercount.  And these numbers are only calculated through December 31st, 2017.
The challenges of responding to any major disaster are enormous, and coming - as this one did - as the third major U.S. disaster in just over a month (preceded by Hurricanes Harvey in Texas & Irma in Florida), resources were already badly strained.
Add in that the hurricane struck an island nearly 1000 miles from the mainland,  whose long neglected infrastructure was already in bad shape - and you have all the necessary plot points for a bad disaster movie.  Except this was no movie.

As a first responder in the 1970s, we had a radio code that - quite frankly - we heard far too often.  It varies by municipality, but where I worked it was 10-89; No Units Available. 
It meant that every ambulance, and every rescue unit, was tied up. No units were available to respond. And the next emergency call might go unanswered for 10, 20, maybe 30 minutes or longer. 
For months after the storm - whether it be restoration of utilities, delivery of food and medicine, or availability of medical care -  much of Puerto Rico was in 10-89 status. And as a result, a lot of people died.
The debate over what could have been done differently will continue, but I can tell you, for a first responder there is no hell quite like not being able to respond when you know you are desperately needed and lives are at stake. 
The question is, was this a fluke? A once-in-a-lifetime disaster that no one could have anticipated, or reasonably prepared for?   Or are we deluding ourselves by believing `it can't happen here (again)'.

Since - until last year - the United States had been in a 10+ year major hurricane drought, the idea of 3 major storms hitting the U.S. in quick succession seemed unlikely.  
But in 2005, we saw a modern record of 28 Atlantic named storms, 7 of which were of major (Cat 3+) intensity.  Nine storms had impact on the United States, although three - Katrina, Rita, and Wilma - were particularly destructive. 
The previous year (2004) also saw 9 U.S. land falling storms, and while not as destructive, no fewer than 5 named storms crossed over Florida, four of which were major hurricanes.

Credit nsf.gov


So the potential for seeing multiple major hurricanes strike in short order - even in the same state - is certainly there.
As bad as these disaster were, they pale in comparison to the 2010 earthquake in Haiti, which probably killed more than 200,000 people.  Or the estimated quarter of a million people who died from the 2004 Indian ocean tsunami, or the tens of thousands who perished from the 2011 Tōhoku earthquake and tsunami in Japan.
But all of these disaster areas have something in common.

It may take weeks, months, or even years before life returns to normal, and the actual loss in terms of mortality, morbidity and permanent disability, PTSD, homes and belongings, businesses, jobs and life savings, and continuity of a community are never fully tallied or appreciated.
We've looked at some of these after effects in the past.
There are always the usual post-disaster accidents; drownings, carbon monoxide poisoning from using charcoal or generators indoors. Falls from roofs or ladders from clearing debris, or chain saw accidents. And even skin infections and food poisoning from contaminated waters (see After The Storm Passes).

Heat (or cold) related deaths may occur when the power is out for extended periods (see MMWR: Heat-Related Deaths During an Extreme Heat Event), and people who rely on oxygen concentrators at home could find themselves in a life threatening situation.
But some after effects may be harder to link to a disaster.
In March of 2009, in a study led by Dr. Anand Irimpen (Associate Professor of clinical medicine at Tulane), it was disclosed that residents of New Orleans saw a 300% increase in heart attacks in the first 2 years after hurricane Katrina.
A follow up, published in 2014 (see Tulane University: Post-Katrina Heart Attack Rates - Revisited), once again found the impact of Katrina on cardiac health remained pronounced.
Also in 2014, in Post-Disaster Stress Cardiomyopathy: A Broken-Hearted Malady, we looked at a rare condition known as Takotsubo cardiomyopathy – or stress induced cardiomyopathy which is often linked to extreme grief or stress, as might be experienced following a disaster.
Also known as broken heart syndrome, this acute ballooning of the heart ventricles is a well-recognized cause of acute heart failure and dangerous cardiac arrhythmias. 
While often hidden from view, the psychological impact of a disaster can be enormous and ongoing. In 2011, in Post Disaster Stress & Suicide Rates, we looked at the impact of disaster-related PTSD (Post Traumatic Stress Disorder). 

This has been recognized as such a pressing problem that the  World Health Organization released a comprehensive Guidelines For Post-Trauma Mental Health Care book on the treatment of PTSD, acute stress, and bereavement in 2013.

Our list of post-disaster sequelae is long, and far from complete.  But it does provide us with an idea of just how much is at risk when a major disaster strikes.

Another CAT 5 storm will strike a populated area of the United States, a major earthquake (M7.0+) will hit a major metropolitan area, and the world will see another severe pandemic.  
It's just a matter of time.  
And when that happens - no matter how well prepared we think we are - we'll wish we had done more.  As a nation, as a community, and as individuals.
The lesson of hurricane Maria is that back-to-back disasters can quickly overwhelm local, state, and federal relief efforts and that failed or damaged infrastructure can prevent needed help or supplies from reaching the victims for days, weeks, or even months. 
While I can't control what FEMA or my state is able to do in response to the next disaster, I do have a say in what I can do.

Living in hurricane country, I've made it a point to have a disaster plan, a disaster buddy, a bug-out destination, and the things I would need to survive without electricity, running water, open grocery stores or pharmacies for a week or longer. 
As long-time readers of this blog already know, I was forced to put all of that into action last year with Hurricane Irma (see A Post Irma Update).
While none of this guarantees me a good outcome when the next disaster strikes, it does better my odds.  And it also allows me to be in a position to help others, either directly, or by not taking immediate assistance from local relief efforts so that it can go to someone else.

For more on the long-term impacts of disasters, and how to prepare for them, you may wish to revisit:
All Disaster Responses Are Local
Supply Chain Of Fools (Revisited)
Little Preps Mean A Lot
In An Emergency, Who Has Your Back?
When 72 Hours Isn’t Enough

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