In addition to catastrophic immediate impacts, communities in the United States remain vulnerable to the long-term effects of severe tropical cyclones and hurricanes caused by storm surge, flooding, and high winds.1 In September 2017, Hurricanes Irma and Maria struck Puerto Rico causing catastrophic damage to the entire commonwealth. Many buildings were damaged or destroyed, including primary care clinics, hospitals, and public health and social services facilities. Essential life-sustaining services such as power, water, and communication were temporarily inoperable, and employment, agriculture, education, and tourism were disrupted.2 In this editorial, we suggest that the Essential Public Health Services (EPHS) framework can be used as a strategic starting point for planning public health system recovery following disasters.
Mortality and morbidity can result from direct impact of a severe storm or indirect impact caused by unsafe or unhealthy conditions resulting in injury, illness, or loss of necessary medical services. A recent report estimated that from September 2017 to February 2018, 2975 excess deaths in Puerto Rico were attributed to Hurricane Maria; residents hardest hit were living in municipalities with lower levels of socioeconomic development, and a large proportion were adults aged 65 years and older.3 Another study suggested that deaths were due to indirect causes such as delayed or interrupted health care.4
Public health departments rely on population statistics and demographics to prioritize prevention efforts and direct recovery resources and are encouraged to collect information on the number and location of at-risk persons to identify priority communities for interventions and to direct public health systems assistance needs. Use of population health indicators to determine future resource needs ensures a more efficient execution of recovery activities.
Efforts to address public health priorities during disaster recovery require coordination with several sectors operating outside public health, such as housing, energy, water, agriculture, sanitation, business continuity, and education. A 2015 Institute of Medicine report suggested that the core functions delivered by the public health sector—assessment, policy development, and assurance—are unique in that they cut across all other community recovery functions.5 By assessing and prioritizing these core functions, public health’s approach to disaster recovery is key to galvanizing a collaborative and multisectoral recovery process.
Public health contributes to predisaster and postdisaster efforts through continual assessment of health status and needs, prioritization of plans and policies, and assurances of access to essential health services throughout the continuum of disaster response and recovery.5 The scope of the damage in Puerto Rico highlighted the need to adopt a multisectoral, whole-community approach to recovery.
Public health systems infrastructure can be optimized by using a framework that supports the entire cycle of emergency management (e.g., prevention, protection, response, recovery, and mitigation). The EPHS framework enhances the ability of health departments to diagnose and investigate health problems in communities and inform people about health issues. Representatives from the US Department of Health and Human Services and other major public health organizations developed the EPHS framework in 1994 to assess capability, document capacity, and improve performance of jurisdictional public health systems.6 Since 2011, this framework provides national standards for the voluntary accreditation of public health departments. It allows professionals to address a range of core public health programs and activities such as public health emergency preparedness, environmental health, access to clinical services, infectious disease, laboratory services, injury prevention, community health, and chronic disease prevention and control. The EPHS framework supports the public health emergency preparedness and response capabilities standards for community preparedness and community recovery by guiding health departments through processes involved in mitigating risks and identifying capability gaps to achieve community resilience.7
To develop an integrated approach for addressing community needs, preparedness activities require pre-event identification of resources and expertise and implementation plans during and after a disaster. The EPHS framework can assist health departments in managing large-scale and complicated public health disasters. It consists of 10 essential functions: Monitor health status to identify health problems Diagnose and investigate health problems and health hazards Inform and educate people about health issues Mobilize community partnerships to identify and solve health problems Develop policies and plans that support individual and statewide health efforts Enforce laws and regulations that protect health and ensure safety Link people to needed health services and ensure the provision of health care when otherwise unavailable Ensure competent public health, clinical health care, and critical service workforce Evaluate effectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problems.61. 2. 3. 4. 5. 6. 7. 8. 9. 10.
The concerted recovery effort to Hurricane Maria may become the largest and longest federal response to a domestic disaster in US history.2 To address the widespread recovery needs of residents of Puerto Rico, a whole community perspective to integrated disaster recovery used a collaborative and interoperable sector-based (i.e., housing, energy, water, transportation, health and social services, public buildings, communications, economics, community planning and capacity building, and natural and cultural resources) organizational approach.5
Following the storms, the government of Puerto Rico developed a long-term recovery plan to identify and prioritize broad systems to address recovery needs, outline potential courses of action (including costs), and align the priorities with potential funding sources. The Puerto Rico Central Office of Recovery, Reconstruction, and Resiliency facilitated plan development through the US Homeland Security Operational Analysis Center, involving federal agencies and municipalities, along with private-sector and nonprofit entities, and community members to highlight and prioritize health and social services courses of recovery intervention within the EPHS framework (Table A, available as a supplement to the online version of this article at http://www.ajph.org).2
Public health response and recovery activities remain resource intensive and may reflect missed opportunities to plan, prioritize, and practice meaningful population health protection based on an understanding of the population’s vulnerabilities or existing public health system limitations. EPHS framework implementation to prioritize and structure response and recovery strategies that target health outcome measures can continue to improve public health emergency management capabilities. The EPHS framework is useful for developing a recovery strategy that can restore a measureable population health protection capacity. The framework also helps to identify the community needs, define goals, select objectives, prioritize interventions, and evaluate outcomes, costs, and effects of the selected actions.6
Data on health indicators and chronic disease outcomes are difficult to acquire; however, knowledge of preexisting risk factors is necessary to determine long-term health needs of the community for planning purposes.5 Incorporation of public health core functions into health department operations and development of an integrated approach to address public health emergency management programs can improve recovery.7
Rebuilding public health system infrastructure will take years to successfully cultivate community resilience. The EPHS framework was a useful tool in Puerto Rico to incorporate public health core functions into health department operations and support updated Centers for Disease Control and Prevention 2018 public health emergency preparedness and response capability standards.7 The EPHS framework outlines those “all hazard” functional preparedness capabilities aligned with community recovery, emergency operations coordination, information sharing, mass care, laboratory operations, surveillance, and epidemiology.7 EPHS framework implementation has utility in rebuilding communities, providing logistical support, and identifying financial and human resources needed to provide sustainable core public health functions after a disaster.
ACKNOWLEDGMENTS
The authors would like to acknowledge the Federal Emergency Management Agency, US Department of Health and Human Services, Centers for Disease Control and Prevention, and Departamento de Salud de Puerto Rico program and staff.
CONFLICTS OF INTEREST
Authors were each deployed as members of the Joint Health and Social Services Recovery Sector following the impact of Hurricane Maria in Puerto Rico.
