February 2018 1

Education, Health & Social Services Briefing Document

Resilient Puerto Rico Advisory Commission

February 2018

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Contents

1 Introduction ______________________________________________________________ 3

2 Overview of Education Issues _________________________________________________ 4

3 Overview of Health Issues____________________________________________________ 4

a. Structural Challenges __________________________________________________________ 4

b. Access and Quality of Care ______________________________________________________ 5

4 Existing Policy Development and Regulatory Context _______________________________ 6

5 Impact of Hurricane on Health Policy Context ____________________________________ 7

6 Resilience in Public Health - Social and Environmental Determinants of Health _________ 8

7 Opportunity Areas ________________________________________________________ 10

a. Relevant Federal/State Recovery Policies _________________________________________ 10

b. Plan de Uso de Terrenos – Developing resiliency through land use planning ____________ 11

8 Conclusion ______________________________________________________________ 13

References _________________________________________________________________ 16

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1 Introduction The education, health and social services section focuses on strategies for improving Puerto Rico’s services within the larger framework of building resilience. Hurricane Maria created an immediate public health crisis from life-threatening flooding and winds, and damage to facilities, buildings and infrastructure. Disruption to essential services including electricity, water supply, and sanitation systems; and contamination of water and food sources posed additional urgent health risks. Prior to the hurricane, the health care system was already stressed due to federal health care funding policies, economic instability and high poverty rates, the aging of the population, and a high occurrence of chronic diseases (e.g., diabetes, heart problems, high blood pressure).

The education system has also faced pre-hurricane issues related to declining enrollment and funding shortfalls, which have been exacerbated by direct physical damage to schools and the accelerated outmigration of students. Disaster recovery provides an opportunity to infuse resilience in these systems by leveraging the re-building process to improve the health care, education and social services systems as well as to comprehensively advance overall social and environmental health to better than pre-hurricane conditions. This includes integrating public health strategies into the recovery process to reduce chronic diseases risk factors, improve equity, and achieve greater resilience and sustainability.

Resilience is defined as the capacity of individuals, communities, institutions, businesses, and systems to survive, adapt, and grow no matter what kinds of chronic stresses and acute shocks they experience. Recovery activities that seek to address vulnerabilities of the public health, education and social services systems will ultimately result in greater and more lasting benefits to individuals, and the community as a whole than if each service area were addressed in isolation. However, Puerto Rico’s economic instability, driven in large part by federal health care and social service funding policies, must be addressed as a prerequisite of any long-term recovery plan.

Main Shocks and Stresses experienced in Puerto Rico

• Aging infrastructure • Coastal & tidal flooding • Declining population / human

capital flight • Increasing elderly population

groups • Economic inequality • Disease outbreaks • Earthquakes • Extreme weather events • Infrastructure failures • Fluvial & pluvial flooding

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2 Overview of Education Issues Schools are important to disaster recovery and contribute to community safety, resilience, and social cohesion. In addition to their primary role in education, schools also serve as centers of community where meals and social services are provided. Educational systems contribute to an environment that supports children’s development, and provides a safe setting for students while their parents are at work. Puerto Rico’s schools were experiencing a fiscal crisis even before Hurricane Maria, due to the commonwealth’s debt and pension obligation. Student enrollment had been decreasing due to the ongoing outmigration of residents, which has accelerated since the hurricane - approximately 22,350 students have left since the hurricane hit, according to the Puerto Rico Department of Education (NPR.org, 2018). School closures increase the disruption and displacement already being experienced by many residents.

3 Overview of Health Issues Chronic Diseases. Puerto Rico suffers from a high rate of chronic diseases. Incidence of diabetes, heart disease, HIV diagnosis rate, and infant mortality are all higher than in the 50 states and DC (The Henry J. Kaiser Family Foundation, 2017). Asthma is also prevalent, and obesity rates in Puerto Rican adults are similar to those in the highest of the 50 states. Primary causes of death, including cancer, heart diseases, diabetes, Alzheimer’s, and cerebrovascular diseases, reflect the Commonwealth’s aging population (Urban Institute, 2017). Research shows that the incidence and severity of many of these chronic diseases can be reduced through changes in the built environment and lifestyle choices. (American Planning Association, EIP-38, 2016).

Vector- and water-borne diseases. Puerto Rico’s tropical climate makes it vulnerable to vector-borne diseases. There are a growing number of Zika virus transmissions, which led the US Department of Health and Human Services to declare the Zika outbreak in Puerto Rico to be a public health emergency in August of 2016. The virus poses a public health and financial challenge —according to the Centers for Disease Control and Prevention (CDC), the dollar amount of caring for a single child with birth defects is estimated to be in the millions (The Henry J. Kaiser Family Foundation, 2016). In addition, dengue is endemic, and the chikungunya virus disease is locally transmitted within Puerto Rico (CDC, 2015 and 2017). Post-hurricane conditions of heat, standing water, and contaminated water are ideal conditions for mosquitoes and other insects to breed and spread such diseases (CDC, 2017). Following hurricanes, there is also an increased risk for Leptospirosis, Hepatitis A, Typhoid Fever, and other gastrointestinal diseases. Reduced access to clean drinking or bathing water, safe food, and shelter can increase the prevalence of such diseases (CDC, 2017).

a. Structural Challenges The shock that Hurricane Maria represented created additional stress on the health, education and social services systems that already faced structural stresses stemming from economic instability, including declining

Education-focused safety, resilience, and social cohesion issues

• Safety: Ensuring the protection and well-being of learners, school personnel, and facilities.

• Resilience: The ability of education systems and learners to withstand, adapt to, and recover from shocks and stresses in ways that promote safety and social cohesion.

• Social cohesion: Promoting a sense of belonging, acceptance by others, and a desire to contribute to the common good.

Source: UNESCO, 2015

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infrastructure, demographic changes and a high poverty rate (Urban Institute, 2017 and The Henry J. Kaiser Family Foundation, 2017). The island has a poverty rate three times higher than that of the 50 states, and an unemployment rate that is more than twice as high (46% of the population is at below 100% of the federal poverty level, compared to 15% of the population of the 50 states). In part due to the high poverty rates, almost half of Puerto Ricans are covered by Medicaid (The Henry J. Kaiser Family Foundation, 2016).

Puerto Rico’s economic recession began in 2006. Between 2006 and 2014, its population had declined by ten percent, primarily due to the largest outmigration of Puerto Ricans to the U.S. mainland since the 1950s. Young people represent a disproportionate share of those who have migrated, with a 25% drop in the number of people between the ages of 0-14 and a 15% drop in those aged 15-44. The number of seniors on the island has increased by 22% since 2006. The aging population also puts more strain on the health care system. In addition, the outmigration includes a substantial number of physicians to the U.S. mainland (The Henry J. Kaiser Family Foundation, 2016).

b. Access and Quality of Care Community health and well-being relies on the existence of an integrated system of facilities and services to prevent,control and treat health problems in everyday as well as emergency response situations (Arup & Rockefeller Foundation, 2015). In Puerto Rico, health care services are largely provided through health insurers operating as Managed Care Organizations (MCOs) which reflects the privatization of the public health care system. Puerto Rico historically had a strong regionalized public health care system emphasizing prevention and sanitation (Urban Institute, 2017). Community health centers play an important role in the island’s health care system; in 2016, twenty health centers operating in 86 mostly rural sites provided comprehensive primary health care to more than 352,000 children and adults – over 1 in 10 residents (RCHN Community Health Foundation, 2017). However, seventy-two of Puerto Rico’s 78 municipalities have been deemed medically underserved areas by the U.S. Health Resources and Services Administration (Urban Institute, 2017).

Pre-hurricane, patients had difficulty accessing specialists, experienced long wait times, and had difficulty paying for prescription drugs. Studies have found evidence of limited access to prenatal services, children’s primary care, specialists, and dental care (Urban Institute, 2017). Regarding vaccination rates, Puerto Rico was found to have low HPV, influenza, and pneumonia vaccination rates compared to the U.S. mainland. In the aftermath of the hurricane, delivery of services became even more challenging; patients with kidney disease were extraordinarily at risk as dialysis centers require power and water to operate. The lack of power caused many dialysis centers across the islands to close. Patients also lacked gas for their vehicles to drive to the centers that remained open (Sullivan, 2017).

Community based organizations have long provided essential services to the island’s most vulnerable populations, according to a study released in December 2016 by the “Red de Fundaciones de Puerto Rico” (Puerto Rico Foundations Network: PRFN) and “Movimento Una Sola Voz (MUSV). The study provided data showing that as government services decline, more Puerto Ricans are seeking the services of community organizations. The study looked at the impact of some 4,500 non-profit institutions that offer services including those related to social service, education, healthcare, and community and economic development such as: SER de Puerto Rico, Boys and Girls Club of Puerto Rico, Sor Isolina Ferré Centers, PECES, Taller Salud, Nuestra Escuela and many others (Red de Fundaciones de Puerto Rico, 2016). Post hurricane, non-governmental organizations have also worked to

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address some of the service gaps. For example, volunteer midwifes at Mujeres Ayudando Madres, or Centro MAM, have been helping with home births, Zika prevention, and prenatal and postpartum health care (Liautaud, Giraldo and Paoli, 2017).

4 Existing Policy Development and Regulatory Context Given the high poverty rate and the aging population, Medicare and Medicaid play an important role in Puerto Rico’s health care system:

• 49% of the population has Medicaid/CHIP coverage, compared to 20% of the population in the 50 states and DC (The Henry J. Kaiser Family Foundation, 2017); Medicare Advantage (MA) serves 570,000 PR seniors and individuals with disabilities. This is the highest rate of enrollment in the US; and

• The private sector health insurance industry is small (1/3 of Puerto Ricans) (Urban Institute, 2017).

Federal financing of the health care system is a major issue affecting both the delivery of services and the economic stability of the commonwealth. For states, the federal government pays a fixed share of costs based on the state’s relative per capita income, while Puerto Rico receives a fixed annual funding cap. The Affordable Care Act provided a one-time supplemental federal grant. This places a huge fiscal stress on the commonwealth. In addition, Puerto Rico’s Governor Ricardo Rosselló has advocated for the inclusion of the Island in the Children’s Health Insurance Program (CHIP) (Ruiz Kuilan, 2017).

Government of Puerto Rico Department of Health (Departamento de Salud or DS) has primary responsibility for the management of all public health programs and services, including the management of the commonwealth’s municipal diagnostic and treatment centers and public hospitals. Services are organized into geographic regions. DS provides health alerts and information, and educational materials (Departamento de Salud, 2017).

“Mi Salud” is Puerto Rico’s Medicaid equivalent, implemented in 2010. It is also used to insure all public employees. Due to inadequate funding, costs have been managed by implementing Medicaid managed care, restricting eligibility, not investing in health information technology, and excluding some benefits. The Government of Puerto Rico’s Fiscal Plan has identified additional measures (fraud detection, expense limits per

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patient, and higher deductible for non-essential benefits) to achieve health care savings (Pietri, 2017). All Mi Salud beneficiaries are enrolled in a managed care program. One of the three goals for Mi Salud’s 2013–16 Quality Strategy is improving access to primary and preventive services (Urban Institute, 2017).

Puerto Rico Health Insurance Administration (ASES) is the agency responsible for overseeing all Medicaid services. ASES contracts with Medicaid MCOs to provide services. Through a cooperative agreement with DS, ASES maintains responsibility for administering public health insurance offered through Mi Salud, Children’s Health Insurance Program (CHIP); Medicare Platino; and coverage for the medically indigent funded by Puerto Rico only (Urban Institute, 2017).

Center for Disease Control (CDC) is an operating component of the Department of Health and Human Services, and focuses on health security and disease control in order to improve the health the people in the United States and its territories. The CDC provides health and travel information, implements grant programs, and participates in projects such as obtaining and distributing Zika Prevention kits (CDC, 2016).

5 Impact of Hurricane on Health Policy Context Hurricane Maria has significantly damaged key transportation, communication, and electricity infrastructure across the island which in turn has exacerbated already challenged health conditions. Damage to schools has contributed to additional stress and instability for students and their families. Major public health concerns include (Kaiser Family Foundation, Michaud and Kates, 2017):

• Mortality. The official death toll on Puerto Rico from Hurricane Maria is widely understood to be underestimated. Officials have stated that there were 472 additional deaths in September 2017 compared to September 2016, though the cause of many of these excess deaths or their potential link to the hurricane has not been certified.

• Food, Water and Sanitation. Many island residents have had difficulties accessing groceries and fresh food. Lack of access to adequate food results in malnutrition, which can cause and exacerbate other health issues. Right after the storm, access to water was minimal, with water treatment and pumping stations knocked out by the storm.

• Health Care Infrastructure. Hospitals, community health centers, and other health care infrastructure suffered extensive damage from the storm, and most hospitals were left without electricity and with limited access to generators with fuel. Almost all of the island’s 47 dialysis centers lost power after the hurricane. Access to treatment and drugs for all types of diseases was challenging.

• Mental Health. Media reports and statements from public health officials indicate that many Puerto Ricans, including young students, are struggling with mental health issues post-hurricane.

• Education. The hurricane damaged schools and supplies, disrupted instruction, and contributed to the continued outmigration of students and their families.

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6 Resilience in Public Health - Social and Environmental Determinants of Health Research shows that improving the overall health of the population requires attention to the broader social, economic, and environmental factors that influence health. The actual delivery of health care services has been shown to be an essential but “relatively weak health determinant” (Kaiser Family Foundation, Heiman and Artiga ,2015). Community design is a key environmental determinant in reducing chronic public health stresses in the long term, and addressing equity issues related to access and environmental justice (American Planning Association, EIP-38, 2016). Factors include:

• Basic infrastructure to provide electricity, clean drinking water, sewage disposal, and streets that are safe for all modes of travel are essential to public health;

• Clean air, water, housing, food;

• Health care facilities, schools, fire and police stations, public transit, and other facilities;

• Provision of parks, playgrounds and public spaces;

• Ease of access to jobs, education, healthy food, and goods and services;

• Protection of open spaces and natural resources that support quality of life, the environment and the economy;

• High quality urban design; and

• Safe and clean neighborhoods that are well-maintained and free from blight, crime, excessive noise, and environmental pollution:

“Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care. …. In the United States, the likelihood of premature death increases as income goes down. Similarly, lower education levels are directly correlated with lower income, higher likelihood of smoking, and shorter life expectancy. Children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health. Their neighborhoods are more likely to be unsafe, have exposed garbage or litter, and have poor or dilapidated housing and vandalism. They also are less likely to have sidewalks, parks or playgrounds, recreation centers, or a library” Source: Kaiser Family Foundation, Heiman and Artiga, 2015.

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Source: Kaiser Family Foundation, Heiman and Artiga, 2015

Many of these are factors that will be addressed by other working groups in the Reimagina Puerto Rico project, highlighting the importance of linkages between health and other sectors when it comes to building resilience in terms of public health.

Approaches to address the social determinants of health include use of technology, data collection and mapping for evidence-based policy and decision making. As described in case studies (see text boxes) there is also increasing attention to “Health in All Policies” approaches that focuses on cross-sector collaboration that considers health and equity impacts in all public policy decisions. Examples of strategies that address health, social services and education issues holistically include:

• Connecting individuals to social services and primary care providers;

• Providing healthy meals and after school programs for students;

• Training and education for expectant parents;

• Health education for nutrition, disease prevention and disease self-management;

• Improving access to affordable, healthy food;

• Planning and re-planning communities for active living (parks and safe places to walk and bike), access to goods, services, and housing; and a clean and healthy environment;

• Leveraging existing relationships and networks to build social capital and community cohesiveness; and

• Fostering long-term collaboration among community-based organizations and health, education, social services, public safety, and urban planning professionals

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(American Planning Association, EIP-38, 2016; and Kaiser Family Foundation, Heiman and Artiga, 2015)

7 Opportunity Areas

a. Relevant Federal/State Recovery Policies The Federal Emergency Management Agency (FEMA) was established in 1979 to coordinate federal disaster policy including preparation, mitigation, response, and recovery. In 2011, FEMA released the National Disaster Recovery Framework (NDRF). The NDRF is a guiding framework that enables effective recovery support to disaster-impacted areas and enables disaster recovery managers to operate in a unified and collaborative manner (see organizational chart below, left). Its focus is how to best restore, redevelop and revitalize the health, social, economic, natural and environmental fabric of the community. Within the NDRF, a framework is provided if a disaster with catastrophic impact occurs to multiple sectors (see below, right). The joint field office (JFO) has a unified group of both state and federal officers and recovery coordinators to deliver recovery support functions (RSFs) for each sector as defined in the figure.1

1 https://www.fema.gov/pdf/recoveryframework/ndrf.pdf

Healthy Community Efforts After Hurricane Ike in Galveston, Texas

In September 2008, Hurricane Ike caused severe flooding on the island of Galveston, Texas, destroying or damaging around 70 percent of the city’s buildings. The city’s 50,000 residents, which included a high number of low-income residents, faced uncertainty as the devastating hurricane compromised health, safety, and communication infrastructure. As a result, investment money reach Galveston during recovery efforts, and the city aimed to utilize funds to recover as a healthy community.

The University of Texas Medical Branch Center to Eliminate Health Disparities (CEHD) received two recovery grants to fund research into post-disaster policy making as it relates to social determinants of health. Social determinants of health include the effects of gender, income, discrimination employment, physical environment, and social support networks on a person’s state of health. The goal of the project was to build an evidence base on Galveston’s local health challenges, create education and community engagement projects that raise community awareness of social determinants of health, and to collaborate with planners in order to incorporate health policies into all aspects of the planning process. CEHD utilized GIS mapping of 125 health-related indicators from the Sustainable Communities Index (SCI) in order to assemble evidence on areas that lack social cohesion, reliable transportation, access to healthy food, and safe housing. The results highlighted the numerous health challenges related the specific areas that the SCI identified, which CEHD then used to advocate for place-specific health policies throughout the recovery efforts.

Source: Institute of Medicine, 2015

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Resilient systems tend to demonstrate seven main qualities: reflectiveness, resourcefulness, robustness, redundancy, flexibility, inclusiveness, and integration (Arup & Rockefeller Foundation, 2015). As such, building resilience in the education, health and social services sectors requires looking at an island or community holistically, understanding the complexities that make up both education and health service systems and the interdependencies and risks they may face to acute shocks and chronic stressors.

Increasing resilience in education and health systems requires an understanding of the environmental and social determinants of health. A healthy community has been defined as one that is “…safe, economically secure, and environmentally sound” with residents that have “equal access to high quality educational and employment opportunities, transportation and housing options, prevention and healthcare services, and healthy food and physical activity opportunities (Institute of Medicine, 2015).” A resilient healthcare system must deliver integrated facilities and services that include: monitoring and mitigation of public health risks, inclusive access to quality healthcare, and adequate emergency medical care and response services (Arup & Rockefeller Foundation, 2015). Galveston Texas, New Orleans, and New York City case studies provide examples of cities that have embraced comprehensive approaches to strengthening public health resiliency as a part of their disaster recovery efforts (see text boxes).

b. Plan de Uso de Terrenos – Developing resiliency through land use planning Land use planning efforts include identifying sufficient and appropriate locations for housing, commercial, public services, employment, and recreation and natural open space uses, in coordination with mobility systems and necessary urban infrastructure. Land use planning best practices also include identifying areas that are most vulnerable to hazards and taking steps to minimize exposure. To build resiliency, it has been recommended to have a holistic cross-sectoral vision, strategy or plan underpinned by appropriate data and delivered via policy, regulations, standards and codes (Arup & Rockefeller Foundation, 2015).

Puerto Rico’s Land Use Plan (Plan de Uso de Terrenos), approved by the Planning Board, Office of the Governor (Junta de Planificacion) in 2015, is a long-range, integrated, comprehensive guide to improving resiliency, promoting economic development, fostering livable communities, and advancing sustainability. It provides a

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vision for Puerto Rico’s urban and rural lands, and was developed through an extensive public outreach process that included government agencies, the private sector and citizens. The plan presents an alternative approach to the existing, pervasive pattern of urban sprawl, which has resulted in loss of agricultural and open space lands, auto dependency, and watershed impacts (Martinuzzi et al., 2007).

Source: Puerto Rico Junta de Planificacion, 2015

Puerto Rico’s Land Use Plan:

• promotes optimal use of land, identifying urban, rural, agricultural and conservation/open space areas;

• supports compact, mixed use development; high quality community design, and a multi-modal transportation system;

• considers the aging of the population;

• is a decision-making guide to enhance economic and social development;

• integrates the land use vision with climate change, socioeconomic development, and legal frameworks;

• protects water resources and promotes adaptive and resilient ecosystems; • promotes just and sustainable development; and • integrates citizen participation as an essential element of planning.

The Plan identifies land that is vacant and suitable for development, as well as calling for conserving at least 582,000 acres (600,000 cuerdas) of land with agricultural value. This comprehensive approach to land use

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planning can help improve the economy, public health, environmental quality and food security among other benefits. The Planning Board is working with municipalities to align with local plans, and to draft new plans where none exist (Junta de Planificación, 2017). Implementation of the Land Use Plan has potential to directly support public health and wellbeing through:

• addressing some of the root causes of chronic disease related to levels of physical activity and access to healthy food;

• providing communities with easy access to parks, open spaces, schools and other public facilities and services;

• attention to equitable redevelopment and high-quality community design; • improving access to health care services through identifying locations for facilities and integrating land

use and mobility planning; • avoiding or minimizing development/redevelopment in areas most vulnerable to hazards; and • applying codes and standards for safe, resource-efficient and resilient homes and buildings.

8 Conclusion As Puerto Rico rebuilds, it has the opportunity to foster a more resilient, healthy and sustainable environment. Key education, health, and social-service take-away supporting cross-cutting issues deemed to be central to Puerto Rico’s resilience recovery include:

Equity & Empowerment. Puerto Rico needs equity with the 50 states in financial support for health care and social services, and design of programs that address long-standing issues of economic instability. Increased funding is also needed for the construction and repair of hospitals, community health centers, health technology infrastructure, schools, and basic infrastructure. For example, retrofitting schools to make them more disaster-resistant is a cost-effective way to provide for the safety of students, personnel and educational investments.

Acute & Chronic Risk Reduction. High rates of chronic disease can be addressed through community design features, as well as integrated delivery of health, education and social services that consider the needs of the whole person and recognize the strong social and environmental determinants of health. Puerto Rico’s Land Use Plan should be used to help guide integrated redevelopment, conservation and economic development activities. The resiliency of health care and education infrastructure as well as basic urban infrastructure can be improved through application of appropriate location, site and building design standards. Place-based mapping, data collection and analysis, and understanding of structural challenges should inform overall policy and prioritization decisions. Actions should be monitored and evaluated for effectiveness.

Leadership. The design and implementation of rebuild strategies requires collaboration among multi-disciplinary experts and community leaders, and an understanding of place-based conditions and needs. Proposals should build-upon the strengths of local institutions and initiatives, including the Land Use Plan and the existing network of neighborhood schools and community health centers.

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Hurricane Katrina and New Orleans

One of the most catastrophic natural disasters in the history of the United States was Hurricane Katrina in 2005, which devastated the Gulf Coast and caused more than $100 billion in damages throughout Louisiana, Alabama, Mississippi, and especially in the City of New Orleans. The city was particularly at risk since water surrounds the city, with nearly half of its land below sea level, and many of the poorest residents living in those low elevation areas. Hurricane Katrina affected 90,000 square miles, killed nearly 2,000 people, and exacerbated poverty conditions in already vulnerable parts of the country (History.com staff, 2009).

In the aftermath of Hurricane Katrina, New Orleans continues to work on recovery efforts, especially in regards to health and social services. Since 1990, the United Health Foundation has ranked Louisiana as 49th or 50th in the U.S. for overall health. In response, New Orleans’ hurricane recovery plans place particular emphasis on transforming community health through partnerships and integrating wellbeing into all aspects of community planning. One example of a successful project from the recovery plans is the cross-sector partnership between the New Orleans Health Department, businesses, schools, and nonprofit organizations, to reinvest in the local health system and emphasize prevention over clinical care though the implementation of new education models. In addition, the partnerships initiated mobile health clinics, new neighborhood health centers, and the establishment of a New Orleans Medical district.

Source: Institute of Medicine, 2015

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Health Resiliency after Hurricane Sandy In 2012, Hurricane Sandy devastated the entire New York Atlantic Coast with severe and extensive flooding, immense infrastructure damages, loss of lives, and disrupted health care services. The hurricane revealed New York’s vulnerabilities associated with inadequate storm surge infrastructure, a lack of affordable housing for displaced citizens, and inefficiencies within the State’s transportation and energy systems.

In the proceeding recovery efforts, governments and resilience planning partners collaborated on a number of strategic plans. In general, the recovery efforts following Hurricane Sandy holistically approached health from the perspectives of improving: provision of healthcare and social services, sustainable and resilient facilities, environmental health, behavioral health systems, and inclusive communities. Resulting projects included a risk assessment on the impact of climate change on healthcare, dedicating more than $100 million to constructing flood barriers for hospitals in flood zones, initiatives to expand the use of electronic health records at primary care and mental health facilities, and providing grant programs for nursing homes to implement mitigation measures. Additionally, New York has constructed a number of creative shoreline protection projects that double as community parks that also further health benefits.

The recovery plans and efforts that immediately followed Hurricane Sandy also informed the more recent One New York: The Plan for a Strong and Just City document, which is a part of the 100 Resilient Cities strategies, in order to provide long-term resilience goals. This effort includes initiatives to reduce poverty, reduce premature mortality, create neighborhood spaces dedicated to advancing women’s health, promote access to breastmilk for newborns, establish Neighborhood Health Hubs that co-locate clinical health and mental health services with social services, build a resilient food system, and encourage all ages to be physically active. Overall, the recovery framework after Hurricane Sandy considered holistic approach to health in the near, short, and long-term.

Source: Institute of Medicine, 2015

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Pietri, K. (2017). Understanding Puerto Rico’s Health Care Crisis. Centro de Estudios Puertorriqueños. [online] Available at: https://centropr.hunter.cuny.edu/events-news/puerto-rico-news/health-care/understanding-puerto-rico%E2%80%99s-health-care-crisis.

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The Henry J. Kaiser Family Foundation. (2016). Puerto Rico: Medicaid, Fiscal Issues and the Zika Challenge. [online] Available at: https://www.kff.org/medicaid/fact-sheet/puerto-rico-medicaid-fiscal-issues-and-the-zika-challenge/.

The Henry J. Kaiser Family Foundation. (2017). Michaud, Josh and Jen Kates. Public Health in Puerto Rico after Hurricane Maria. [online] Available at: https://www.kff.org/other/issue-brief/public-health-in-puerto-rico-after-hurricane-maria/.

The Henry J. Kaiser Family Foundation. (2017). Puerto Rico: Fast Facts. [online] Available at: https://www.kff.org/disparities-policy/fact-sheet/puerto-rico-fast-facts/.

UNESCO. (2015). Incorporating safety, resilience, and social cohesion in education sector planning. [online] Available at: http://education4resilience.iiep.unesco.org/sites/default/files/booklets/1_planning_en.pdf.

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Urban Institute. (2017). Environmental Scan of Puerto Rico’s Health Care Infrastructure. [online] Available at: https://www.urban.org/sites/default/files/publication/87016/2001051-environmental-scan-of-puerto-ricos-health-care-infrastructure_1.pdf.

Urban Institute. (2017). Puerto Rico Health Care Infrastructure Assessment: Site Visit Report. [online] Available at: https://www.urban.org/sites/default/files/publication/87011/2001050-puerto-rico-health-care-infratructure-assessment-site-visit-report_1.pdf.

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