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Puerto Rico faced persistent economic and sociodemographic challenges prehurricane

• Before Hurricanes Irma and Maria, overall rates of chronic disease in Puerto Rico were higher than U.S. averages.
• Migration away from the island has decreased Puerto Rico's workforce and its tax base.
• A lack of fiscal transparency and accountability hampered the government of Puerto Rico's ability to address these large challenges.

Health care facilities sustained major damage from the hurricanes

• Damage to buildings and electrical, water, and communications infrastructure closed clinical and diagnostic medical facilities—some for several months.
• Where facilities remained open, services were compromised by intermittent access to power and water, lack of access to client records, and limited staff.
• Strain on the health care network was amplified when hospital and health clinic use increased posthurricane.

Health impacts were wide-ranging in the wake of the hurricanes

• The presence of mold, debris, pests, and waterborne vectors produced unsafe living conditions in highly impacted areas.
• Increases in anxiety, depression, and post-traumatic stress disorder (PTSD) were widely reported.
• Gastrointestinal outbreaks at schools, increased incidences of conjunctivitis and influenza, and deaths from leptospirosis were reported.

Social services that could avert negative health outcomes were also disrupted

• Locating and identifying people after the storm were hampered by data access difficulties.
• Gaps in benefits and supportive services for distributing food/nutrition, medications, and supplies affected the population's health and well-being.

In September 2017, Puerto Rico was struck by two major hurricanes—Irma and Maria—that intensified existing challenges in Puerto Rico's health and social services infrastructure. In the aftermath, the government of Puerto Rico created a long-term recovery plan built on an evidence-based assessment of the damage from the hurricanes and the ongoing needs across Puerto Rico. Development of the recovery plan was supported by the Federal Emergency Management Agency, other federal agencies, local stakeholders, and analysis from the Homeland Security Operational Analysis Center (HSOAC), operated by RAND Corporation under contract with the U.S. Department of Homeland Security.

HSOAC research provided the foundation for the 31 courses of action in the recovery plan addressing the health and social services sector. These actions are a mix of social, governmental, fiscal, and economic policies and reforms. This collection of actions presents an opportunity to build a more resilient health and social services infrastructure and regional health care networks to ensure reliable access to services, promote health and well-being, and more efficiently and effectively respond to public health crises and future disasters. The actions span the areas of health care, public health and emergency preparedness, environmental health, mental and behavioral health, and social services.

The damage and needs assessment and courses of actions cover four major themes: building system capacity to respond both during disasters and routine times; strengthening the health and social services workforce; strengthening support services for at-need populations; and creating health-promoting communities.

• Chapter One

  Introduction

• Chapter Two

  Puerto Rico's Health and Social Services Sectors Before the Hurricanes

• Chapter Three

  Damage and Needs Assessment

• Chapter Four

  Themes for Recovery and Courses of Action

• Chapter Five

  Implementation Considerations

• Appendix A

  Courses of Action

• Appendix B

  Health and Social Services Sector COAs

• Appendix C

  COAs from Other Sectors Included in the Health and Social Services Portfolio

• Appendix D

  Health and Social Services Portfolios

• Appendix E

  Plan Development