Opinion: The Conflicting Narratives of Hurricane Maria: Rethinking Disaster Response

By: Elizabeth J. Ashbourne (Executive Director, Partnership for Quality Medical Donations – PQMD) and Verónica M. Arroyave (Director / Global Community Relations, Executive Director / Baxter International Foundation, Baxter International Inc.)

On September 20, 2017, Hurricane Maria slammed into Puerto Rico as a Category 4 storm and the island experienced widespread devastation.  In December 2017, the official death toll stood at 64. However, a study, released May 29, 2018, funded by the Harvard T.H. Chan School of Public Health and others, and published in the New England Journal of Medicine, sheds light on a long-suspected concern suggesting initial estimates were woefully underestimated, placing the associated death toll closer to 5,000 – roughly 70 times the original number. Even more recently, an independent study commissioned in February by the Puerto Rican government estimates Hurricane Maria caused 2,975 deaths in Puerto Rico in the six months following the storm. The study, led by researchers at George Washington University, was commissioned after public pressure that the government’s initial hurricane death toll was grossly underreported.

Damage from Hurricane Maria along the shoreline of Puerto Rico. (Courtesy photo Bristol-Meyers Squibb)

5,000 or 2,975-if one considers death tolls as the principal way to understand the impact of a disaster on a community-these findings illuminate an even broader conundrum, a problem of two conflicting narratives. The first narrative, coming from government reports, is one of a well-handled disaster relief effort with health service delivery restored and patients getting needed care. The other story is one where the beleaguered population and island remains vulnerable and laboring to regain its footing. And more importantly, the spotlight falls squarely on an island where aid and relief efforts are still very much needed. The truth no doubt, exists somewhere in the middle, beyond the immediate impact, with the long-term human and environmental scars of Hurricane Maria on Puerto Rico still being felt today.

The context of the disaster in Puerto Rico was made no less easy by 2017’s hyperactive disaster season and the rapid sequencing of fateful events, making it feel like a pandemic of disasters. With 17 major disasters happening in the U.S. alone, aid and relief efforts were strained, national communication and health service delivery systems were disrupted, and NGOs themselves struggled to staff events amidst the successive situations. This was further exacerbated by the “disaster after the disaster” – a health system weakened by greater health demands and affected health facilities left without electricity and water and inadequate sanitation.

Despite significant progress in promoting a culture of disaster resilience, the response and recovery community continues to confront colossal economic losses and continued high mortality rates in many parts of the world. And this precisely illuminates the broader issue at play: that despite all of the expertise and contributions of those that rushed to the aid of the many affected in Puerto Rico, why has it not been enough to restore the lives of 3.4 million American citizens?  Was it a lack of personnel, resources, information, communication, coordination or resilient systems? This event and relief provided to date certainly suggests a disconcerting quagmire for the relief community broadly writ to advocate for a paradigm shift.

Admittedly, there is no one-size-fits-all approach to ensuring access to quality health services and care in a disaster situation. And with a growing trend to develop alternative and more resilient community disaster response models –what will a new paradigm look like? What elements from the 2015-2030 Sendai Framework, UN SDG Goals, Global Health Security Agenda, and others can help us advance a paradigm shift?  Health systems do not live and operate in a vacuum. As organizations and institutions with expertise, funds, and resources dedicated to alleviating the impacts of disasters and humanitarian crisis, are we adequately including all the stakeholders? How do we need to rethink partnerships, how they operate, and what they can (and should) provide? What are we missing in our efforts to promote access to medical products and services, and a well-articulated systems approach to disaster response? And, who else needs to be at the table?

The Role of PQMD

From the day the storm made landfall in Puerto Rico and throughout the Caribbean, Partnership for Quality Medical Donations (PQMD) members actively responded and now, nearly a year later, continue to do so because while the United States is able, the island is still in need. An active and long-standing coalition of pharmaceutical, medical product and device companies, and NGOs, PQMD members have extensive expertise in delivering high quality medical services during crisis and humanitarian disasters. PQMD members sprang into action donating upwards of $253M in cash contributions by corporate members, and many times that in gifts-in-kind health product donations to provide immediate and longer-term relief to a health system and infrastructure buckling under the weight of the crisis. Since then, PQMD members and partners continue to support the relief and reconstruction efforts being made for housing, roads, power, and water, and filling gaps in areas related to humanitarian assistance.

At PQMD’s 2018 April Global Health Policy Forum, senior policy and thought leaders gathered to consider what we know about disaster response and where the gaps and opportunities to rethink how we approach disasters and other humanitarian crises to improve resilience and create more sustainable systems to respond to natural disasters and humanitarian emergencies.  Three main themes emerged in this exchange: the importance of innovation in an era of collaborative transformation, the challenge of global health governance & accountability in emergency situations, and the need to better define and measure health outcomes.

In his keynote address, Jeff Sturchio from Rabin Martin posed the central framing question of our event:

How can we best design resilient and sustainable health systems that draw on all available resources and expertise to improve health for all?”

He posited that systems thinking, coalition building, and fostering resilient communities would all be elements of a comprehensive approach.  Simply responding to emergencies, wherever they occur, is good but not sustainable. Resources of the humanitarian assistance community continue to be stretched, never more so than in 2017 when an estimated 128 million people were impacted by some disaster, and all in need of urgent humanitarian aid. It is essential that NGOs, companies, and governments alike build disaster preparation capacity for local health systems and be ready to adjust to pursue sustainable health solutions.

To that end, maintaining focus on people and communities was repeatedly cited as necessary to achieve comprehensive and effective disaster response. Training of likely affected populations in disaster response is effective because they are first to respond and have the motivation to repair their communities. Local communities also have the social and community capital to pool their resources and address the issues most important to the community’s survival. Training local staff, in advance of an adverse event, empowers them and creates a sense of ownership and leadership when a crisis of disaster strikes.

As evidence suggests, establishing public-private partnerships prior to a disaster is critical to building the capacity of local health systems and improving high-potential, sustainable solutions, particularly given the diverse capabilities and resources of NGOs and corporations. Claire Hitchcock from GlaxoSmithKline maintained that “collaboration is the way forward,” and encouraged organizations in the health sector to bring in other sectors and clearly identify roles and responsibilities in any emergency response plan. Ms. Hitchcock also noted that GSK’s disaster response strategy now includes long term programs focusing on training workers and strengthening health systems. In the same vein, Mr. Sturchio added that “thinking more systematically about the interconnectedness of health systems will help us understand how to address disparities in access, improve health outcomes and incentive more equitable allocations of scarce resources.”

The significant resources of corporations, including financial, logistic, product and human, are also key players in disaster response efforts. So, where do we go from here? What is the path forward in light of the lessons learned, and observations shared, both through the lens of the 2017 disaster season as well as discussions between public and private stakeholders dedicated to addressing the disaster in Puerto Rico and others that are on the horizon?

While there are many things that the global community is getting right, there is a sense that we have still not figured out how to address the most critical urgent needs. While we have reduced the amount of disaster-related deaths overall, it is clear that money, products, medical support, mature partnerships, and substantial investment and goodwill are still not enough to meet the critical health needs of a population in crisis.  We clearly still need to improve communication, coordination, and collaboration. Additionally, partnerships, especially those formed long before disaster strikes, are critical and essential to short term and long term disaster response, but what else should we be doing? The extensive resources and capabilities of corporations support the efforts of their NGO partners and provide a community presence in affected areas but what more can be done?


Robert Glasser, UN Secretary-General’s Special Representative for Disaster Risk Reduction[i], said that “…if we do not succeed in understanding what it takes to make our societies more resilient to disasters then we will pay an increasingly high price in terms of lost lives and livelihoods.”  This point is further driven home by the fact that United Nations estimates that economic losses from disasters are now averaging $250 to $300 billion USD each year not including the human and environmental losses.[ii]

Fundamentally with losses of this magnitude, how do we hyper advance collaborative transformation? How do we catalyze our cross-sectoral community of practice to integrate the disaster response and recovery imperative with our evolving philanthropic donation system to converge elements of successful models to change the paradigm?

Jane Nelson, of the Harvard Kennedy School, recently argued the importance of building coalitions and partnerships to implement cross-sectoral solutions that bring new thinking, new resources and new solutions to bear in ways that accomplish more together than individual members of a coalition can do on their own.  If PQMD’s experience is in any way an example, it has learned that the most effective donation programs are those that are delivered through broad coalitions of partners, each of whom has a specified role within the network, all focused on achieving a common objective.

Proposing a paradigm shift is not an attack on the existing humanitarian assistance architecture, but rather a call to action for a unified front to re-engineer a system that has primary drivers focused on efficacy, incentivized by coordination and innovation. The success of a paradigm shift depends on both the willingness and the ability of communities, disaster relief stakeholders and responders to fully integrate access to healthcare and resilience into prevention, mitigation and response strategies.

[i] https://www.unisdr.org/files/54837_2017no13.pdf

[ii] https://www.unisdr.org/archive/50981