"Y no quedó nada, nada de la casa, todo salió volando" (And there was nothing left, nothing of the house, everything flew away): a critical ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Vega Ocasio et al. BMC Public Health (2021) 21:1833
https://doi.org/10.1186/s12889-021-11847-w
RESEARCH Open Access
“Y no quedó nada, nada de la casa, todo
salió volando” (And there was nothing left,
nothing of the house, everything flew away):
a critical medical ecological perspective on
the lived experience of hurricane María in
Puerto Rico
D. Vega Ocasio†, J. G. Pérez Ramos† and T. D. V. Dye*†
Abstract
Background: Ecological disasters create dramatic changes as man-made and natural ecosystems adapt to their
effects. In 2017, Hurricanes Irma and María devastated Puerto Rico. Public focus after such traumatic ecological
events often neglects pre-existing community dynamics, heterogeneity of lived experience, and complexity of
decision-making in the disaster context. We intended to better understand the lived experience of this ecological
trauma in communities across ecosystems in Puerto Rico and among those displaced to Florida.
Method: We used the Critical Medical Ecological (CME) framework to assess the relative contribution of ecological
dimensions on lived experience across community levels and time. We used qualitative methods with emic coding
and etic mapping of salient constructs to the ecological model. In total, 96 people participated in 23 discussion
encounters. Two people coded interviews in Spanish using Dedoose. We identified common themes in sequential
order mapped to elements of the CME to approximate the participants’ temporal experience.
Results: Codes applied to the period of the hurricane’s landfall, traverse, and exit were markedly distinct from the
other two periods (before and after) examined in this study: the experience of the hurricane’s strike was highly
personal and, at this level, reflected a mix of sociocultural, biological, and abiotic factors. After the hurricanes, social
and community factors re-emerged while new risks and conditions arose that were biological (e.g., leptospirosis, no
food or water) or abiotic (e.g., unusable roads/bridges, structures destroyed), but created ongoing stressors and
social needs for communities. As we found, the dynamics of the social and household landscape sometimes
involved the decision to leave Puerto Rico altogether, or forced people to continually face and adapt to the
ongoing collapse in basic services that were only slowly and differentially restored.
* Correspondence: tim_dye@urmc.rochester.edu
†
D. Vega Ocasio, J. G. Pérez Ramos and T. D. V. Dye share joint first
authorship.
Department of Obstetrics and Gynecology, University of Rochester, School of
Medicine and Dentistry, 601 Elmwood Avenue, Box 668, Rochester, NY
14642, USA
© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 2 of 28 Conclusion: Lived experience across each stage of the hurricanes differed substantially from one another. Communities disrupted by ecological disaster are also frequently entangled within global economic and political histories and dependencies that could preclude recovery. Island nations are especially vulnerable to both climate- induced ecological change and political-economic exploitation. The ongoing health effect of the hurricane remains palpable in many communities of Puerto Rico and among the diaspora in Florida. Keywords: Puerto Rico, Disaster, Ecosystem, Hurricane María, Social determinants, Diaspora, Medical ecology, Critical perspectives, Qualitative, Trauma Background significantly destabilized natural and built environments Ecological disasters – increasingly more common and - killing an estimated 250,000 people - but the subse- frequently attributed to climate change – create disba- quent social disaster after the earthquake, including a lance among physical environments, biological risks, and widespread, uncontrolled cholera epidemic, killed far health care, and disrupt lives and communities that are more [13, 14]. The consequences of the 2010 earthquake nested within them [1]. Dramatic changes occur in hu- in Haiti still reverberate in communities and in the ecol- man populations post-disaster as man-made and natural ogies that sustain them, with populations displaced, ser- ecosystems adapt to their effects through recovery and vices disrupted, and infrastructure destroyed long after regeneration, achieving homeostasis and driving toward the earthquake itself [15, 16]. Similarly, the tsunami in stability or a “new normal” in both nature and society Southeast Asia in 2004 killed 230,000 people in a short [2–4]. Public focus surrounds the occurrence of disas- period of time, yet the destabilizing and socially destruc- trous events with rescue, provision of aid, population tive impacts toppled governments, caused infectious dis- exodus, and recovery; this focus often centers on visible ease outbreaks, and dissolved communities long after effects of the disaster event itself, neglecting pre-existing [17–19]. community dynamics, heterogeneity of lived experience We employed the Critical Medical Ecological frame- of the disaster, and the complexity of decision-making work [20] (Fig. 1) to examine the relative contribution of (or, lack of agency to make decisions) post-event. Often social, biological, abiotic, and health care dimensions on the “disaster” stretches far before and far beyond the lived experience across communities, households, and ecological events that characterize them and adopting among individuals before, during, and after the hurri- such a longitudinal perspective can help explain commu- cane disaster in Puerto Rico. We aimed to describe the nity change, while incorporating the additive impact of lived experience in communities across ecological zones the event – on individuals, households, communities, in Puerto Rico and among Puerto Rican community and nations - itself [5]. members displaced to Orlando, Florida to more compre- In September of 2017, Puerto Rico was devastated by hensively understand the pre-hurricane context, to de- two powerful hurricanes, Irma and María, 2 weeks apart. lineate the chronological stressors arising from the Hurricane María, the strongest hurricane to hit Puerto hurricanes, and to describe the resulting adjustments Rico in more than a century, caused devastation across and impacts in communities. We used qualitative the archipelago [6]. The damages manifested by this hur- methods with emic (local perception) coding and etic ricane destroyed telecommunication systems, energy, (external) mapping of salient constructs to the ecological and water infrastructures, reshaped coastlines, damaged model to explore the dimensions of this disaster, not roads, caused mass deforestation, and destroyed homes. knowing in advance exactly what dynamics and con- The toll from Hurricane María was estimated at more structs would emerge as prominent in accounting of than 4000 people dead [4, 7, 8], and with an estimated lived experience. 212,000 people or more migrating away from the archi- pelago [9]. Methods The consequences of human entanglement in eco- Research team and reflexivity logical disasters are the immediate loss of agency and The research team had several layers. This project was the creation of vulnerability in populations shocked and embedded in a larger CDC-funded initiative partnering living within disrupted environments [10, 11]. The with Puerto Rican communities and the University of events witnessed and experienced by living through the Puerto Rico [21], with Dr. Dye and Dr. Pérez Ramos in- disaster itself are tragic, disruptive, surreal, and impact- volved from the beginning, including a research pause to ful, and frequently usher a post-event social and eco- create the #p2p4PUR (people-to-people for Puerto Rico) logical disaster that creates even more disruption and hurricane relief initiative [22]. Drs. Dye and Pérez Ramos suffering [12]. For instance, the 2010 earthquake in Haiti came to know many of the communities involved in this
Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 3 of 28 Fig. 1 Critical Medical Ecological Multileveled Analytical Framework: Lived Experience Before, During, and After 2017 Hurricanes in Puerto Rico present study through their efforts with the CDC-funded Rico, they did not have prior experience nor existing re- initiative and #p2p4PUR. After the hurricanes of 2017 search relationships in Orlando, Florida, but networked and with resumption of the team’s research in Puerto through social and professional contacts to reach re- Rico, Dr. Vega Ocasio and Dr. Ivelisse Rivera joined Dr. search partners. Dye and Dr. Pérez Ramos in creating the protocol that Project participants knew that the field team was governed this project. As a demonstration of equity and Puerto Rican, based in Rochester, New York, and had to deliberately avoid a hierarchical structure, the four in- conducted health research in Puerto Rico before. The vestigators (Drs. Vega Ocasio, Rivera, Pérez Ramos, and team members from Puerto Rico were from different Dye) serve as Co-Principal Investigators. All four Co-PIs parts of the country and had different diaspora experi- were deeply familiar with Puerto Rico, with family in the ences in the USA. The team members introduced them- islands, and directly impacted by the hurricanes. The en- selves before interviews or focus groups started, sharing tire field team was fluently bilingual (Spanish and Eng- this background. The presence of Latin American, lish), and culturally Latin American and all coding team Caribbean, and European-American team members (in members were fully bilingual (Spanish-English) with the field team and in the wider analytic team) helped us Spanish as their first language. Two team members iden- bring both etic and emic perspectives to coding and tify as men and six as women. Several team members analysis. were full-time PhD students in the University of Roche- ster’s Translational Biomedical Science program at the Study design time of their involvement with this project. Our work examining the lived experience of the 2017 The investigator team had pre-existing relationships hurricanes among Puerto Rican residents and the dias- with some communities or individuals within particular pora used the medical ecology paradigm as a heuristic locales before starting this work. In some cases, the team device [20, 23]. Medical ecology is particularly well- networked through other contacts to reach interested suited to help organize data and to help interpret envir- organizational partners at the community level. While onmental or ecological-related events in the social, bio- the team had prior experience conducting fieldwork and logical, health care, and physical environments. The in coordinating the aid response throughout Puerto model requires that we attend to multiple levels of
Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 4 of 28 organization (individuals, households, communities) and typically restricted to formal legal and contractual trans- across domains (biological, sociocultural, abiotic, health actions, and a signature would be the only written iden- care), address the processes of stressors and adaptations, tifier in this study. An IRB-approved information sheet and evaluate different types of data. For this project, about the project and protections, with contact details while the medical ecological paradigm helped us shape for the investigators and IRB, was provided to partici- the development of an interview guide, the fieldwork pants. Topics and discussions often branched from the was predominantly ethnographic and qualitative. This original script, following a local format of conversation. approach allowed for full expression of community One field investigator guided the interview and the other voices to capture lived experience. took notes. A third attended to logistics of recording, Participants met the inclusion criteria of a) Age 18 and processing paperwork, and assisting participants and over, b) self-identified as Puerto Rican, and c) were resi- moderators as needed. Refreshments were provided to dent in Puerto Rico, the USA, or relocated to the USA all participants. Due to local institutional requirements since the hurricanes. We worked with local community and cost of participating, Orlando participants received organizations in Puerto Rico and in the USA, who serve $20 gift cards. All participants were provided with refer- the populations impacted by the hurricanes to help ral sheets in the interview that listed local and national organize discussion groups and interviews (identifying hotlines, resources, and suggestions for counseling and venues, setting times, staffing check-in, referrals). We assistance, and any local referrals were handled by part- deliberately included a range of geographic locations to ner organizations. The investigator teams debriefed at help capture variety in experience, and conducted the end of each day, summarizing that day’s experience groups and interviews in urban, mountain, coastal, and and planned for the next. All recordings were tran- outer island locales throughout Puerto Rico. Specifically, scribed by people for whom Spanish was their first lan- we included the following types of municipalities and guage, and transcripts were edited and corrected by ecosystems in our study, “Urban/Metro,” “Mountain,” project team members. Community participants did not “Coastal,” and “Outer Island.” In the state of Florida, we review completed transcriptions. Demographic questions concentrated groups and interviews in Orlando, to (place of residence, gender) were self-reported. where most Puerto Ricans who left Puerto Rico for the The average time for group interviews in Puerto Rico mainland after the hurricanes relocated [24]. was 70 min, and in Orlando 90 min. The average individ- We worked with local community partner organiza- ual interview lasted 73 min. Repeat interviews were not tions in each ecological zone to identify potential partici- conducted and each participant participated only once. pants in their catchment areas through flyers distributed No one refused to participate and no one refused or through social networking and word-of-mouth. In recording. total, 96 people (31 men, 65 women) participated in a total of 23 discussion encounters (17 focus groups (four of which were in Orlando), 6 interviews). Groups were Data preparation and analysis hosted in organizational or community facilities and in- We developed a mixed codebook, mostly using terviews were completed in spaces determined by grounded procedures (emic codes) but also with several participants. model-led codes (etic) [26]. First, the seven coders and The ethnographic instrument used was the same for investigators reviewed a sample of transcripts, generating individual and group interviews, and was pretested with a list of candidate codes arising from the data. Those the project team and with people for whom Spanish was codes were reviewed, merged, and consolidated. Next, their first language. The interview guide was structured codes were applied to a sample of transcripts and a final using Spradley’s “Grand Tour” and “Experience” ap- codebook assembled. The final codebook (Additional file proach [25], asking participants to describe sequentially 1) contained thematic, structural, theoretical, narrative, how events unfolded before, during, and after the storms and descriptive codes and subcodes. The final codebook and with questions asking participants to recount their contained definitions and examples for coders to refer- lived experience. For participants in Orlando, we asked ence, and was entered into Dedoose for cloud-based more experiential questions regarding their decisions, coding [27]. The codebook was ordered sequentially to circumstances, and lived experiences of relocating from capture the chronological sequence of pre−/during Puerto Rico to Florida. Following presentation of the In- −/post-hurricane emic codes followed by investigator- formation Sheet with IRB-required language, partici- driven etic codes. pants provided verbal informed consent to participate in While themes were not determined in advance, codes the interview and also to be audio recorded. Documenta- were mapped to the component of the medical eco- tion of written consent was waived since literacy is un- logical model with which they best fit, to facilitate ana- clear, formal signing of documents in this population is lysis within the medical ecological framework.
Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 5 of 28
Coders were trained with a 10% sample of records in Florida (as a representation of a recent Puerto Rican
Dedoose until > 90% agreement was accomplished, with diaspora group) to capture a range of environmental and
discrepant codes discussed and resolved. Subsequently, lived experiences. Codes (see Qualitative Codes in Ap-
two coders fully coded every interview, again with dis- pendix A) were applied 3484 times to the Spanish-
crepant codes discussed and resolved to achieve a final language transcriptions from the focus groups and inter-
coded transcript. We used a range of analytic methods views. In total (Fig. 2), codes from the “Before the Hurri-
in Dedoose to identify frequency of codes, to pull ex- cane” period (n = 691) accounted for 21% of all code
cerpts for closer manual analysis, to examine code co- applications, with an additional 9% (n = 285) applied to
occurrences and to stratify codes by geographic unit the “During the Hurricane” time period, and with the
(rural, urban, mountain, coastal, outer island, and majority of code applications – 70% (n = 2405) – applied
Florida). to the “After the Hurricane” time period. An additional
Analysis consisted of identifying the most commonly 122 code applications were generic or administrative, ap-
coded themes, and presenting codes and themes in se- plied across all time periods. Overall, across all time pe-
quential order to approximate the participants’ temporal riods, half of the codes applied related primarily to the
experience. Examples are presented from each code to “Community” domain of the ecological model (Fig. 2),
illustrate both typical and outlier situations to help por- followed by codes located within the “Individual” do-
tray the full range of lived experience. Codes were main (37%), and “Household-related” codes (13%). Simi-
assigned domain (sociocultural, abiotic, biological, and larly, slightly more than half of the applied codes related
health care) and level (individual, household, and com- to the “Sociocultural” domain, one-third of the codes ap-
munity) values that were aggregated over the total plied related to the “Abiotic” domain, 12% to the “Bio-
period, and the periods before, during, and after the hur- logical” domain, and 2 % in the “Health Care” domain.
ricanes. These summaries are presented as multilevel
qualitative models to synthesize the types of ecological
dynamics of each period. Part a: before the hurricane
Each partner organization provided a letter of support Overall, half of the codes applied in reference to the
after reviewing the protocol, materials, and discussing period before the hurricanes related to the Community
the project with investigators. The University of Roche- level of the ecological model (see Fig. 3), while 41% of
ster’s Research Subjects Review Board reviewed and ap- codes applied in this period related to Household level
proved the project (RSRB00071756) as expedited, issues, and with 7 % of the codes applied to the Individ-
minimal risk research. All investigator and research team ual level. All of the codes applied from the period before
members completed CITI Program research, ethics, and the hurricanes related to either Social (58%) or Abiotic
compliance training required by the University of Roch- (42%) factors, with no codes applied in the Biological or
ester. Dr. Pérez Ramos and Dr. Dye also completed the Health Care domains during this period.
required ethics training from the University of Puerto Shown in Table 2, overall “hurricane preparation”
Rico earlier for the parent project. (considered predominantly as a Household-level/ Abiotic
We used the Consolidated Criteria for Reporting set of codes, Fig. 3) was the most commonly-mentioned
Qualitative Research (COREQ) checklist [28] to organize theme (particularly in the metro areas) when partici-
the reporting of qualitative findings. pants recalled the period before the hurricanes –– as
people assembled food and water supplies, protected
Results windows with shutters, and relocated to shelters or to
As shown in Table 1, a total of 97 people from Puerto the homes of relatives. Lack of preparation was also
Rico (51 women and 46 men) participated in the study. commonly noted, especially in coastal and rural areas, in
Participants were recruited from different ecological particular a lack of prevention by government agencies.
zones of the archipelago of Puerto Rico and in Orlando, Participants in coastal and metro areas noted that
Table 1 Participants demographics by ecosystem/ region
Geographical Region Number of Individual Interviews Number of Focus Groups Women Men Total of participants
Coastal 2 6 22 12 34
Metropolitan Area 0 3 6 3 9
Outer Island 3 1 5 0 5
Rural 1 3 12 10 22
Florida, USA 0 4 6 21 27
Total 6 17 51 46 97Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 6 of 28
flooding was already frequent common in their commu-
nities, even before María.
From a participant who lives in a rural, coastal area:
“Nosotros, en mi casa empezamos una preparación,
pero al ir a las ferreterías no habían paneles ya y el
precio que te estaban dando por un panel de un
cuarto de PVC era sobre 40 dólares. El presupuesto
no daba para comprar siete u ocho paneles que yo
necesitaba. En mi caso yo rompí los closets y tapé
las ventanas que eran de cristal, las que pude con la
poca madera que tenía dentro de mi casa, sacamos
y cubrimos la parte de, que es la que, como yo vivo
en una lomita, la que recibe la mayor parte del
impacto pero no fue suficiente. Me preparé con lo
poco que tenía, forré y lo demás, compra y eso
siempre los suministros para esta época pues en casa
siempre se suplen, pero en el trabajo de ventanas,
eso no se pudo hacer más que la mitad porque en
las ferreterías la gente ya había sacado todo el panel
que había y lo que quedó pues no fue suficiente.
Y nosotros pues, el dinero no daba para comprar
el material necesario para-- no había tormenteras
y mis ventanas son de cristal. Lo poco que se
pudo hacer, se hizo, lo demás pues se quedó a la
intemperie y fue lo que sufrieron las
consecuencias.”
“We started a preparation at my house, but when
we went to the hardware stores there were no
panels anymore and the price, they were giving you
for a one-quarter PVC panel was about $ 40. The
budget was not enough to buy seven or eight panels
that I needed. In my case I broke the closets and
covered the windows that were glass, which I could
with the little wood that I had inside my house, we
took out and covered the part of, which is the one
that, since I live on a mound, the it receives most of
the impact but it was not enough. I prepared myself
with what little I had, I lined and the rest, buy and
that is always the supplies for this time because at
home they are always supplied, but in the work of
windows, that could not be done more than half be-
cause in hardware stores the People had already re-
moved all the panel there was and what was left was
not enough. And we, therefore, the money was not
enough to buy the necessary material for ... there
were no storm shutters and my windows are glass.
The little that could be done was done, the rest was
left out in the open and it was what suffered the
Fig. 2 Qualitative code application by time period, domain, and
level of the ecological model
consequences.”
From a participant who lives in a rural, coastal area:Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 7 of 28 Fig. 3 Distribution of qualitative codes by ecological level and ecological domain by period of the hurricanes (before, during, after)
Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 8 of 28
Table 2 Most commonly applied qualitative codes before Hurricane María with examples, by geographic area
Exemplary Supportive Quotes
Theme Coastal Metro Outer Island Rural Diaspora
Preparación “Y yo por lo menos en “Los otros huracanes “Yo me preparé con lo “Por lo menos “Llega el momento en
para el mi casa yo trepé casi que yo había vivido, básico porque yo nosotros en casa nos que ya como pasa
huracán todo en bloques que el último más decía “mi casa” para preparamos por tanto tiempo, porque
(Hurricane porque yo vivo cerca grande fue George, yo ese entonces porque menos con los nenes, no esperábamos,
Preparation) del lago y trepé mis era pequeña así que ya yo no vivo en esa, con los medicamentos, verdad, todo el tiempo
(Ecological muebles, los zapatos yo no sabía mucho de era, es bien pequeña, para la fiebre, los escuchábamos al
Model Level: de los nenes, todo yo preparación de entonces, este yo, al medicamentos para gobierno que estaban
Sociocultural lo traté de subir.” [And huracanes, ver el último “live” de las alergias de ellos, preparados, pero no
domain) at least in my house I honestamente yo tuve Ada Monzón, yo me por varios días, y nos decían para
No. of mentions: put everything in blocks que meterme en asusté tanto que hice agua, y las cuanto tiempo
168 (4.8%) because I live near a lake, google y en llamar a hasta bulto porque mi tormenteras. Lo más estaban preparados, y
and I raised the furniture, mi papa como para nene tenía seis meses importante para mí entonces ahí es donde
the children shoes, “como te preparas para ese entonces yo son los medicamentos entró el pánico
everything, I tried to para un huracán” decía “si pasa algo yo de ellos.” [“At least we verdad, de que uno
make it higher] ¿verdad?. Así que tengo que salir at home prepare for less dice, “wow”, yo tengo
No. of mentions (%): básicamente hice lo corriendo” y en with the babies, with the gasolina o diésel para
63 (4.4%) mismo que habían Vieques es difícil medicines, for the fever, tanto tiempo” pero
hecho mis padres para porque para ese the medicines for their hasta cuándo va a
prepararse para tiempo no va a haber allergies, for several days, durar esto, cuando ya
huracanes lancha, no va a haber and water, and the storm entonces las
anteriormente porque vuelos. Y…..Entonces racks. The most gasolineras no tienen
yo no conocía de hice bultos, este…mi important thing for me is diésel, ni gasolina, ahí
adulta huracanes.” [The esposo llenó más agua their medications.”] es que entonces viene
other hurricanes that I por si nos No. of mentions: 55 lo peor.” [“The time
had lived, the last biggest quedábamos sin agua (5.4%%) comes when so much
was George, I was little y nada, nos time passes, because we
so I didn’t know much encerramos ahí en la did not wait, right, all the
about hurricane sala porque time we listened to the
preparation, honestly I considerábamos que government that they
had to google and call era el lugar más were prepared, but they
my dad to ask: “how do seguro porque era did not tell us for how
you prepare for a donde menos habían long they were prepared,
hurricane” right? So, I ventanas y como que and then that is where
basically did the same la ventana estaba ya the panic entered the
thing my parents had reforzada y pues…a truth, that one says,
done to prepare for esperar.” [“I prepared “wow”, I have gasoline or
hurricanes before because myself with the basics diesel for so long “but
I didn’t know hurricanes because I said “my how long is this going to
as an adult”] house” at that time last, when the gas
No. of mentions (%): because I no longer live stations have no diesel or
9 (3.3%) there, it was, it is very gasoline, that’s when the
small, so when I saw the worst comes.”]
last live of Ada Monzón, I No. of mentions(%): 19
was so scared that I (3.7%)
prepared a bag because
my baby was six months
old at that time I said “if
something happens I
have to run” and in
Vieques it is difficult
because at that time
there will be no boat,
there will be no flights.
And ... I prepare my bags
… my husband filled
them with water in case
we ran out of water and
we locked ourselves there
in the room because we
considered it to be the
safest place because it
was where there were
fewer windows and the
window was already
reinforced and well ...
then we waited”]
No. of mentions (%):Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 9 of 28
Table 2 Most commonly applied qualitative codes before Hurricane María with examples, by geographic area (Continued)
Exemplary Supportive Quotes
Theme Coastal Metro Outer Island Rural Diaspora
9(3.4%)
Situacion “Uno de los “La limpieza y eso “No, no hay gasolina, “Yo considero un “Eh, el clima, el clima
Sociales problemas más puede acarrear a los no vienen trucks de problema económico estaba contaminado,
(Social grandes que tiene habitantes de estas comida porque los el hecho de, al vivir en había muchas
Circumstances) Rincón es la salud, comunidades un sin ferrys los paran la región noroeste y la personas con
(Socio-cultural como tal. Es que aquí números de completamente.” [“No, mayor parte de los dificultades
domain) hay mucha población condiciones de salud, there is no gasoline, no trámites grandes se respiratorias,
No. of mentions envejeciente, por que sobre todo por las food trucks come hacen en San Juan, de infecciones en los
(%): 119 (3.4%) ende, muchos de esos inundaciones, las because the ferries stop las agencias pulmones, eh,
familiares quedan gastritis, la dermatitis, them completely.”] gubernamentales, problemas con los
solos en sus casitas, el asma. Después del No. of mentions (%): 27 cada vez que uno mosquitos, con el
enfermos. Aquí en huracán vimos mucha (10.2%) sube allá, nada más famoso dengue, por lo
Rincón, no hay una asma, mucha son cincuenta dólares menos en donde yo
ambulancia.” [“One of conjuntivitis. Este… de gasolina más el vivía si.” [“Um, the
the biggest problems Hubo casos de peaje, subir y bajar.” climate, the climate was
Rincón has is health, as piojos.”[“Cleanliness and [“I consider an economic polluted, there were
such. There is a large that can lead to the problem the fact that, many people with
aging population here, inhabitants of these living in the northwest respiratory difficulties,
therefore, many of those communities a number region and most of the lung infections, uh,
relatives are left alone in of health conditions, large procedures are problems with
their houses, sick. Here in especially floods, gastritis, done in San Juan, by mosquitoes, with the
Rincon, there is no dermatitis, asthma. After government agencies, famous Dengue, um, at
ambulance”] the hurricane we saw a every time one goes up least where I lived yes”]
No. of mentions (%): 41 lot of asthma, a lot of there, it is only fifty No. of mentions(%): 7
(2.9%] conjunctivitis. This ... dollars of gasoline plus (1.4%)
There were cases of lice”] the toll, go up and
No. of mentions (%): 9 down”].
(3.3%] No. of mentions (%):
35(3.5%)
“Para nada, yo no me preparé. O sea, había una agency was prepared, even though they have more
compra que habíamos hecho, cobramos el cheque y knowledge than the people, no one was prepared
hacemos la compra grande del mes. Yo no vi en mi there.”
casa preparación porque “no vamos para ningún
lado, nos vamos a trancar aquí y mañana es otro Almost all codes applied at both the Community and
día, nada va a pasar”” Individual levels in the period before the hurricanes re-
lated to sociocultural factors (Fig. 4). For instance, par-
ticipants also noted challenging social circumstances
“Not at all, I didn’t prepare. In other words, there that pre-existed the hurricanes such as crime, violence,
was a purchase that we had made, we cashed the and unemployment in communities, and migration from
check and we make the big purchase of the month. Puerto Rico to the USA. Outer island residents were
I did not see preparation in my house because “we particularly concerned about crime in their
are not going anywhere, we are going to lock up communities.
here and tomorrow is another day, nothing will From a participant living in an outer island:
happen”
“Muchas veces está bien tranquilo, pero llega una
From a participant living in a rural area: temporada que está caliente, empiezan los robos,
empiezan a asaltar, la verdad? La guerra de la calle
“Lo que pasa es que mira la gente dice “entonces, no y pues estamos en ese tiempo ahora, que no puede
te preparaste” pero el gobierno está preparado, nadie estar por ahí mucha, mucho…. Verda? Sola… no
está preparado, ninguna agencia de gobierno se pre- puedes estar tan tarde por ahí y tienes que tener cui-
paró, aun teniendo más conocimiento que el pueblo, dado donde te metes.”
ahí nadie se preparó.”
“Many times, it is very calm, but there comes a sea-
“What happens is that when people look, they say son that is hot, the robberies begin, they begin to
“then, you did not prepare” but the government is assault, right? The street war and well we are in that
prepared, nobody is prepared, no government time now, that there cannot be around much,Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 10 of 28
Fig. 4 Multivariate qualitative code distribution of ecological domain by level (community, household, individual) and time (before, during,
after hurricanes)
much…. Right? Alone… you can’t be that late out “Aquí trataron de montar un puntito [drogas ilíci-
there and you have to be careful where you go.” tas] acá en frente y los mismos vecinos nos organiza-
mos y le caímos arriba a los muchachos, un poquito
From a participant living in a coastal zone: problemático”.Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 11 of 28
“Here they tried to set up a little point [illicit drugs] the individual level, some participants said that they felt
here in front and the same neighbors organized our- their faith was a tool to protect them from harm.
selves and we fell on top of the boys, a bit From a participant living in a coastal area:
problematic.”
“Algunos decían que no iba a venir nada, “no, eso
Several Orlando participants indicated that people no viene nada”. Eso es como en otros casos que la
were already leaving the island in the times before gente decía como el cuento del lobo, viene y viene y
María. Participants who eventually migrated to Flor- a última hora me preparo, gasto y no viene.”
ida were less likely to mention their communities as
tranquil before the hurricanes arrived and generally “Some said that nothing was going to come, “no,
were less likely to mention preparedness-related nothing is coming.” That is like in other cases that
issues. people said like the story of the wolf, it comes and
From a participant living in Orlando: it comes and at the last minute I prepare myself, I
spend and it does not come.”
“…que en el área médica los médicos ya se están
yendo de Puerto Rico, y hay, hay especialistas que From a participant living in a coastal area:
no, que ya ni existen. O sea, básicamente. O sea que
antes que pasara María, es como dijo el caballero, “Entonces “Dios mío mami, entonces ¡Ay Dios! yo no
fue el-el-el último hachazo que nos dieron, ¿verdad?, puedo creer que esto va a pasar” ¿sabes?, entonces
para que Puerto Rico terminara como está.” [comenzamos] rogando a Dios “vete, vete por la cur-
vita y vete por otro lado” porque Irma lo hizo así.”
“... that in the medical area the doctors are already
leaving Puerto Rico, and there are, there are special- “Then “My God, mom, then Oh God! I can’t believe
ists who are not, who no longer exist. I mean, basic- this is going to happen” you know, then [started]
ally. In other words, before María passed, it is as the praying to God “leave, leave on the curve and go the
gentleman said, it was the-the-last hack that they other way” because Irma did it like that.”
gave us, right? So that Puerto Rico ended as it is.”
From a participant living in a coastal area:
From a participant living in Orlando:
“Yo tenía miedo de lo que llegara a suceder, pero yo
“No hay para lo cual se sacrificaron, y como dicen estaba confiado de verdad, de que, si pasaba algo,
en mi campo, se pelaron las pestañas. Si nosotros yo iba con Dios porque yo estoy en la iglesia.”
como padres hasta nosotros mismos los impulsamos
a que busquen bienestar y yo tengo tres hijos var- “I was afraid of what would happen, but I was truly
ones. Los tres se me salieron para acá ya hace más confident that, if something happened, I would go
de los últimos cuatro años. Con dolor en el alma vi to God because I am in church.”
a nuestros hijos partir con nuestros nietos sacándolos
de-de prácticamente de debajo de nuestras sábanas, Despite these challenges, participants frequently de-
pero buscando bienestar.” scribe their communities before the hurricanes as tran-
quil and unified. Consistent with these sentiments, some
“There is none for which they sacrificed themselves, participants noted that they underestimated the level of
and as they say in my field, they peeled their eye- destruction that was about to come.
lashes. If we, as parents, even encourage them to From a participant living in a rural, mountainous area:
seek well-being and I have three sons. The three of
them left me here for more than the last four years. “Aquí, como todo el mundo se conoce, entonces pues,
With pain in my soul, I saw our children leave with este se unen. Entonces pues, todo es tranquilo,
our grandchildren, pulling them out practically from ¿sabes? Mayormente tranquilo. Este, no tenemos así,
under our sheets, but seeking well-being.” pues, problemas mayores de pelea, ni robo. Este,
pues, podemos, pues, tratar de convivir juntos y
Some participants mentioned a sense of “invincibility” vamos, poco a poco, uniéndonos, este, como dijo.”
before the hurricanes and that no harm would come to
them, with a few noting that the comparatively low “Here, as everyone knows each other, then, well,
amount of damage from Hurricane Irma may have cre- they come together. So, everything is quiet, you
ated an air of overconfidence in facing María. Also at know? Mostly calm. This, then, we do not haveVega Ocasio et al. BMC Public Health (2021) 21:1833 Page 12 of 28
major fighting problems, nor robbery. This, then, “But we did not expect the thump that came.”
we can, therefore, try to live together and we will,
little by little, unite, this, as he said.” Part B: during the hurricane
Codes applied to the period of the hurricane’s landfall,
From a participant living in a metro area: traverse across Puerto Rico, and exit (see Figs. 3 and 4)
were markedly distinct from the other two periods (be-
“Eh… es una, es una comunidad relativamente area fore and after) examined in this study: the experience of
tranquila que uno tiene una comunidad al lado que the hurricane’s strike was highly personal (reflected by
de hecho son una, que de hecho son los residentes most codes – 92% - relating to the Individual level) and,
originales de esa área que dura como un poquito at this level, reflecting a mix of sociocultural, biological,
más de ingresos, verdad, más humilde, más pobre”. and abiotic factors (Fig. 4). Specifically, the predominant
themes of participants from the period before the hurri-
“Eh ... it is a, it is a relatively quiet area community canes (see Table 3) were fear and anxiety (in the Bio-
that one has a community next to it that in fact are logical domain), and experiences related to the wind (in
one, that in fact are the original residents of that the Abiotic domain).
area that lasts a little more income, right, more Participants described Hurricane María’s experience
humble, poorer.” mostly as one filled with fear and anxiety (see Table 3),
most prevalent in those living in coastal areas followed
From a participant living in a mountainous area; by those living in rural areas. The main causes of fear
and anxiety were described as a result of a rapidly deteri-
“Tuvimos el evento de [Hurricane] Georges. Eso fue orating built and natural environment during the storm,
en el ‘98, ese fue fuerte. Pero anunciaban muchos combined with not knowing what was happening due to
fenómenos que venían, y muchas veces, pues, no lle- communications black-outs (telephone services, internet,
garon, por suerte se desviaban. Había como una and social media). This uncertainty, combined with the
confianza de... digo muchos, ¿verdad? Yo entiendo strong winds and the darkness, made individuals feel
que tuvimos como una confianza de que se iba a fearful.
desviar. A lo mejor en muchos lugares no nos pre- From one rural, coastal participant:
paramos como... porque de hecho, nadie, por lo
menos, de esta generación, nadie había visto algo “Era como si fuera eterno. No acababa. Nos metimos
tan fuerte como esto.” en la iglesia como desde las siete de la noche hasta
el otro día que terminó el huracán. Y era un miedo
“We had the [Hurricane] Georges event. That horrible, y la puerta comenzó a hamaquearse, la de
was in ‘98, that was strong. But they announced enfrente, y estábamos en esa de que en cualquier
many phenomena that were coming, and many momento se fuera a despegar. Y el agua entrando
times, well, they did not arrive, luckily, they de- por las ventanas.”
viated. There was like a confidence of ... I mean
many, right? I understand that we had a kind of “It was as if it was eternal. It didn’t end. We went into
confidence that he was going to deviate. Maybe church from about seven at night until the other day
in many places we don’t prepare like ... because the hurricane ended. And it was a horrible fear, and
in fact, at least no one from this generation, no the door began to swing, the one in front, and we
one had ever seen something as strong as this.” were in the position that at any moment it would take
off. And the water entering through the windows.”
From a participant living in a coastal area:
From a participant living in a rural area:
“Pusimos tormenteras en la puerta del frente pero
jamás y nunca pensábamos que se iba a ser como “Pero a mí me dio ansiedad cuando no había nin-
fue.” gún tipo de comunicación. No había forma de... no
había celulares, no había, este, televisión, no había
“We put storm shutters on the front door but never, señal. Este, bueno, tampoco tenía luz, no había”
never thought it was going to be the way it was.”
“But it gave me anxiety when there was any type of
From a participant living in a rural town: communication. There was no way to … there were
no cellphones, no television, there was no signal.
“Pero no esperábamos el fuetazo que vino.” This, well, we had no electricity either, there wasn’t”Vega Ocasio et al. BMC Public Health (2021) 21:1833 Page 13 of 28
Table 3 Most commonly applied qualitative codes during Hurricane María with examples, by geographic area
Exemplary Supportive Quotes
Theme Coastal Metro Outer Island Rural Diaspora
Fear and “Después cuando el “Si seguía lloviendo. “Sí, cuando, ese “Yo sentí miedo, “Y, cuando pasó el
Anxiety viento empezó había Había muchas teorías momento cuando el cuando sentí que la huracán yo estaba
(Biotic que apagamos el de ¿Por qué fue que árbol le da al carro, que casa se movía.” [“I felt refugiada en una
factors) televisor, entonces se ocurrió la inundación? ahí empezamos a fear, when I felt that the iglesia. Resulta que la
No. of fue la luz. Entonces La más fuerte que ha escuchar, no sabíamos house was moving”] iglesia es de dos
mentions pasamos un susto bien sonado es que lo que se escuchaba, Isabela niveles, y la parte de
(%): 78 grande porque se cayó supuestamente verdad? lo que era, No. of mentions (%): 18 abajo tiene un colegio.
(2.2%) un palo que estaba al abrieron las puertas del pero se escuchaba tan (1.8%) Había treinta familias
lado de quenepa y Lago La Plata, las fuerte. Eche yo estaba allí. Resulta que, en el
rompió la reja de la abrieron porque estaba bien asustada… Yo paso del huracán, el
casa y pasamos un ya en su límite y que no literal me metí una techo de la iglesia se
susto bien grande. La avisaron a nadie, ellos Benadryl a ver si me abrió en dos, y la iglesia
casa se conmovió dicen que sí, que dormía, pero los se desplomó
muchas veces como prendieron las alarmas nervios eran tantos que completamente la parte
temblor de tierra. Yo de tsunami, pero nadie no pude dormir. Fue de arriba. O sea que la
pensaba que la casa se las escuchó y pues toda bien fuerte.” experiencia mía fue mas
iba a caer del techo y esa agua bajó; al haber [“Yes, when, that moment difícil aun, porque tuve
entonces yo decía tantos escombros pues when the tree hits the car, que pasar el huracán
“¿Dios mío que yo hago se desbordó el agua y which we started to listen allí en vivo, que eso
aquí?”, entonces se inundaron todas to, we didn’t know what fue… teníamos el agua
pensaba meterme al estas comunidades”. was being heard, right? acá arriba. Pensábamos
baño por si acaso [“If it kept raining. There what it was, but it que nos, que nos
pasaba algo, pero ¿y si were many theories of sounded so loud. Eche I íbamos a morir, porque
en el baño se cierra la Why the flood happened. was very scared ... I literally esa estructura empezó
ventana? ¿Se tranca? The loudest that has put a Benadryl to see if I a temblar. Entonces, no
Me voy a ahogar. Me va sounded is that they fell asleep, but the nerves tuvimos ropa algunos
a pasar algo pensaba supposedly opened the were so much that I could por tres días, bueno. La
yo y eso.” [“Later when gates of Lake La Plata, not sleep. It was very historia es larga.” [“And
the wind started, we had they opened them because strong.”] when the hurricane
to turn off the TV, then the it was already at its limit Vieques happened I was sheltering
power went out. Then we and that they did not No. of mentions (%): in a church. It turns out
had a very big scare warn anyone, they say yes, 1(0.4%) that the church is on two
because a stick that was that they turned on the levels, and the lower part
next to quenepa fell and tsunami alarms, but no has a school. We had
broke the fence of the one heard them and then thirty families there. It turns
house and we had a very all that water went down; out that, in the passage of
big scare. The house shook As there is so much rubble, the hurricane, the roof of
many times like an the water overflowed and the church was split in
earthquake. I thought the all these communities were two, and the church
house was going to fall off flooded.”] completely collapsed on
the roof and then I said Santurce top. In other words, my
“My God, what am I doing No. of mentions (%) 9 experience was even more
here?” So I thought I would (3.3%) difficult, because I had to
go to the bathroom just in go through the hurricane
case something happened, there live, that was ... we
but what if the window is had the water up here. We
closed in the bathroom? thought that we, that we
Does it lock up? I’m going were going to die, because
to drown. Something is that structure began to
going to happen to me I shake. So, we didn’t have
thought and that”] any clothes for three days,
No. of mentions (%): 48 well. The story is long.”]
(3.4%) No. of mentions(%):
2(0.4%)
Stories “Y no quedó nada, nada “Bueno, en mi caso yo “El viento era… Era una “En mi casa el viento se “Una ventana que no
about de la casa, se llevó la estuve agarrando furia, era… o sea yo llevó todas las está para afuera, está
the wind nevera, todo lo que ventanas para que no pasé Georges, yo me tormenteras que daban dentro de la casa, da
(Abiotic estaba alrededor de la se abrieran y mi hija, acuerdo de Hugo. Pero para atrás... se las llevó para la sala, de un
factors) pecera, todo salió agarraba otra. En mi realmente esto fue, todas, y las tiró para un cuarto para la sala, hizo,
No. of volando. Como es como casa hay una puerta esto no se… ni… esto lado y al otro día empezó a sonar así a la
mentions un laberinto, el viento que es como de cristal no se compara. No se amanecieron en la una que todavía no
(%): 49 daba regresaba y nos y a mi mamá le daba compara.” [The wind was dirección había nada y eso me
(1.4%) batía porque fue como miedo que se fuera a ... It was a fury, it was ... completamente levantó. Después de
una máquina de moler salir, así que ella la that is, I passed Georges, I opuesta de donde eso, nada, empiezo con
y allí fue destrozando abrió un poco y se remember Hugo. But really salieron”. [“In my house mi esposo a escuchar la
todas las casas. quedó velándola desde this was, this I don’t the wind carried away all radio, y todo y eso eraVega Ocasio et al. BMC Public Health (2021) 21:1833 Page 14 of 28
Table 3 Most commonly applied qualitative codes during Hurricane María with examples, by geographic area (Continued)
Exemplary Supportive Quotes
Theme Coastal Metro Outer Island Rural Diaspora
Después tú notabas que lejos que no se fuera a know… nor… this doesn’t the thunderstorms that un monstruo sonando
se terminó, ya en mi volar. Ella entró en compare. It does not were giving backwards ... cuando empezó el
casa no estaban los crisis porque el compare.”] it took them all, and pleno, yo creo que eran
vientos, pero yo veía el televisor estaba No. of mentions (%): 3 threw them to one side como las tres y media
resto de viento enfrente a esa puerta (1.1%) and the next day they de la mañana y eso era
destrozando las casas. de cristal, y empezó, woke up in the completely un monstruo, realmente
No hubo virazón como “¡Pero mueve la opposite direction from tú escuchabas un
antes. En mi casa puerta!”, y yo la miro y which they came”] monstruo, lo que tú
explotaron las ventanas yo, “Ahora no es la No. of mentions (%): 17 escuchabas por las
y se metieron hacia hora, lo siento por ti, sí (1.7%) ventanas eso era un
adentro.” [“And there was se va el televisor bye, monstruo que estaba
nothing left, nothing from bye, tv”, pero gracias a afuera.” [“A window that
the house, he took the Dios no le pasó nada. is not facing the outside, is
refrigerator, everything that Si, nos quedamos inside the house, it opens
was around the fish tank, agarrando las puertas” up to the living room, from
everything flew away. As it [“Well, in my case I was a room to the living room,
is like a labyrinth, the wind grabbing windows so they it did, it started to sound
would return and beat us wouldn’t open and my like that at one o’clock
because it was like a daughter grabbed another. that there was still nothing
grinding machine and In my house there is a and that lifted me. After
there it was destroying all door that is like glass and that, nothing, I started
the houses. Later you my mother was afraid that with my husband listening
noticed that it was over, it would leave, so she to the radio, and
the winds were no longer opened it a little and kept everything and that was a
in my house, but I saw the watching from afar that it monster sounding when
rest of the wind destroying would not fly away. She the plenary session began,
the houses. There was no went into a crisis because I think it was like three
turn as before. In my house the TV was in front of that thirty in the morning if
the windows exploded, glass door, and she more or less there) And
and they went inside”] started, “But move the that was a monster, really
No. of mentions (%): 18 door!”, And I look at her you heard a monster, what
(1.3%) and I, “Now is not the you heard through the
time, I feel sorry for you, windows that was a
yes the TV bye, bye, tv”, but monster that was outside”]
thank God nothing No. of mentions (%): 4
happened to him. Yes, we (0.8%)
were holding the doors.”]
No. of mentions (%):
7(2.5%)
From a rural, mountainous area: “So, then, as the situation increased, we were
getting nervous, right? Because it is something
“Entonces, pues, según iba aumentando la situación, that we are not… unknown. So, this, when we all
nos íbamos poniendo nerviosos, ¿verdad? Porque es gathered here, the family, well, they left the front
algo que no… desconocemos. Entonces, este, cuando door open, right, and when that storm started ...
nosotros nos reunimos todos aquí la familia, pues, well ... I say, for me, I had never seen something
dejaron la puerta del frente abierta, verdad, y like this so strong. Because when Georges, this,
cuando comenzó esa tormenta... pues….digo yo, para that was at night, and it scared me because the
mí, yo nunca había visto algo así tan fuerte. Porque house kind of vibrated and was a terrible hum.
cuando Georges, esto, ese fue de noche, y me dio So, well, I thought that could happen. But they
miedo porque la casa como que vibraba y era un left the door open and everyone there, looking
zumbido terrible. Entonces, pues, yo pensé que eso out the door because the wind blew in here, this
podía suceder. Pero dejaron la puerta abierta y way out front. And it was like a smoke, the water
todos ahí, mirando por la puerta porque el viento se became like a smoke, that you didn’t see
metió por aquí, por aquí al frente. Y era como un anything. Just a buzz, right, like a bellow of
humo, el agua se convertía como en un humo, que something ...”
tú no veías nada. Solamente un zumbido, verdad,
como un bramido de algo...” From one participant – who had relocated to Orlando:You can also read
