October 17, 2019: When Hurricanes Irma and Maria lashed the Caribbean in 2017, the U.S. Virgin Islands experienced devastation similar to Puerto Rico, including massive disruption to their healthcare system, but with less media fanfare. The extent of damage unleashed by these storms on medical care in the U.S. Virgin Islands is only now coming into focus, thanks to research by UF's Emerging Pathogens Institute Director J. Glenn Morris and College of Medicine Interim Dean Adrian Tyndall.
With only two weeks separation in September 2017, Hurricanes Irma and Maria sped through the Caribbean and left a trail of tropical troubles. But while media attention focused on Puerto Rico’s unprecedented and widespread destruction, the U.S. Virgin Islands were largely left out of the global spotlight — despite losing the only emergency-equipped medical center available to St. Thomas and St. John.
The extent of damage these storms unleashed on medical care in the USVI, home to 55,000 people, is only now coming into focus. In a new study published Oct. 17 in the American Journal of Public Health, UF’s Emerging Pathogens Institute Director, J. Glenn Morris, M.D. and M.P.H, and College of Medicine Interim Dean Joseph Adrian Tyndall, M.D. and M.P.H., teamed up with investigators from the University of Maryland School of Medicine, Baltimore, to analyze how these twin hurricanes affected healthcare in the USVI.
“There is general agreement that the U.S. failed to provide aggressive, post-hurricane support in Puerto Rico,” says Dr. Morris, who is the study’s corresponding author and a professor of infectious diseases in UF’s College of Medicine. “But what our paper does is document for the first time that this was a huge problem in the U.S. Virgin Islands too.”
The islands’ only emergency room-equipped medical center, St. Thomas’s Schneider Regional Medical Center, saw its fourth floor collapse due to damage from Hurricane Irma’s category-five winds, which topped out over the island at 178 mph. Wind and flooding caused extensive damage to the roof and windows, the emergency department flooded, and the hospital’s cancer center was destroyed. Just two weeks later, Hurricane Maria blew by with top winds of 64 mph, but comparatively greater rainfall which triggered mudslides and flooding.
The study analyzed records and found that approximately 800 patients were evacuated between both storms — with at least 171, but likely 282 or more, evacuated by air — to medical centers in St. Croix, Puerto Rico and the U.S. Medical evacuations were estimated to take 12 to 18 hours and cost tens of thousands of dollars per patient. Incomplete records mean that even today, it is not documented where some patients went, the study reports. Worse, their fates are not always known: 49 died, and there is follow-up data on only 536. Five hundred are still receiving care off-island, while at least 125 have returned home at the time of this writing.
“We want to fully understand what happened to patients, and patient outcomes, during and after these 2017 hurricanes so that we can devise better recovery strategies and plan for future storms,” Dr. Morris says.
Only five deaths in the U.S. Virgin Islands were officially attributed to the hurricanes. But just as Puerto Rico later revised their death toll, the research team suspects that the actual number of storm related deaths is much higher, possibly several hundred.
“There was a clear impression that the potential number of casualties were far greater than what was suggested in the media, and this has continued to go unnoticed and underappreciated,” Dr. Tyndall says. “The destruction that occurs as a result of these natural disasters lasts far beyond a few new cycles.”
The researchers interviewed nurses, physicians, and administrative staff; scoured FEMA press releases; and extracted data from almost 600 emergency department patient encounters. Two hundred encounters occurred before the storms, and 388 after the hurricanes (nine were missing dates). They also analyzed 10,716 administrative records (4,804 pre-, 957 inter-, and 4,955 post-hurricane).
The team found that nurses and physicians both expressed concern about patients with chronic conditions losing continual access to care or support networks, which then resulted in a spike of emergency room visits after the hurricanes which otherwise would have been prevented.
Hospital administrators expressed competing needs to repair damaged structures, replace equipment – such as the island’s only MRI – and wrestled with questions of “rebuilding, replacing, or accepting the loss of facilities.”
The majority of visits the day after Hurricane Irma were due to injury, while patients with diabetes had elevated visits for the three months post-hurricane compared to the time period before the storms.
Most patients seeking treatment after the hurricanes were older, male, and self-pay; they also tended to have less acute illnesses than were seen before the hurricanes. The study authors interpret this as evidence of the breakdown in social and familial support networks that would normally care for this patient demographic.
There is a greater trend of aging-in-place in Afro-Caribbean communities, compared to aging in skilled-care facilities as is more common in the U.S. and elderly people were likely left unsupported by their normal social networks due to storm-related disruptions. Disaster recovery efforts tend to focus on physical infrastructure rather than social support networks, the authors note.
Two months after the hurricanes, hospital staff noted a spike in asthma and respiratory related illnesses, which is consistent with other studies documenting an increase in airborne mold after urban flooding disasters.
FEMA Public Assistance paid about $530 million for recovery through March 2018, with half of this going into physical infrastructure. SRMC received $2.6 million in grants and $28 million in FEMA loans. The researchers argue that with this level of funding, the healthcare system is struggling to “systematically plan and develop a resilient system which can respond to inevitable future hurricanes.”
“Looking back, did we do enough?” Dr. Morris asks. “There was some support, but it was limited, in a highly chaotic setting. Given what we know about sea temperatures increasing, there will be more hurricanes. So we have to start thinking about what we can do better next time.”
Dr. Tyndall notes that a fragile economy and medical system, such as the USVI’s, can amplify the after-effects of natural disasters and lead to disrupted care and loss of life in ways that area often underestimated. “Understanding this impact, we have to also fully understand the root causes of the often times inadequate support provided,” he says. “The fragility of the medical ecosystem should also inform better preparation and prepositioning of assets to support the longer-term impact of these natural disasters.”
Other UF researchers who contributed include Muhammad Abdul Baker Chowdhury, M.P.H. and M.P.S. (first author); Andrew Fiore, B.P.H.; Scott Cohen, B.S.; Meenakshi P. Balakrishnan, Ph.D. and M.P.H.; Michael Chami, M.D.; Laura Scieszka, M.D.; Matthew Drabin, B.S. and from UF’s College of Public Health and Health Professions. Additional contributors include USVI hospital staff Clayton Wheatley, M.D. and Bernard Wheatley, M.D., and from the University of Maryland School of Medicine in Baltimore: Kelsey Roberts, B.S.; Alexander Toben, B.S., and Lynn Grattan, Ph.D.
Sidebar: Undergraduate Research
Andrew Fiore, UF Class of 2019, took part in this study as Dr. Morris' undergraduate mentee. Fiore took a chance and contacted Dr. Morris to explain his interest in becoming an epidemiologist and to inquire if there were any research projects he could participate in at the EPI. “I knew it was a long shot, but he was at the top of my list,” Fiore says. “He laid out a few projects, but half I didn’t qualify for because I did not speak Haitian creole. The one I qualified for, and thought I could dig my teeth into, was the Virgin Islands project.”
Fiore quickly became part of the team that traveled to the USVI to extract medical records. He also assisted in notating a group interview with hospital staff, and after returning home he wrote up results from the interviews and combed through FEMA press releases.
The project became Fiore’s senior thesis for his Bachelors of Public Health (UF College of Public Health and Health Professions). The research experience proved transformative.
“Dr. Morris had a hand in changing what I thought I wanted to do,” Fiore says. “I’ve known I wanted to be an epidemiologist ever since I was fourteen. But he demonstrated to me the value of biomedical knowledge in this field, and he showed me that epidemiologists can be medical doctors too.”
Fiore is currently pursuing pre-professional courses to qualify for admission to a medical program.
Written by DeLene Beeland; photo by Dr. Laura Scieszka of the Schneider Regional Medical Center after recovery efforts had taken place.
Read J. Glenn Morris's profile here.
Read Joseph Adrian Tyndall's profile here.