Democracy as a Public Health Policy

A new study from the University of Michigan reports that Puerto Rico received significantly less help than Florida or Texas in the 2017 hurricane season. The total numbers of people and funding resources were smaller, and the response was slower. The result? Unnecessary levels of death and destruction.

Scott Greer, a professor of health management and policy and of global public health at the university, described the situation as “a reminder of the penalties of not being fully represented in federal politics.”

“Democracy is a public health policy,” explained Mr. Greer.

Unequal response

The British Medical Journal’s Global Health journal published the results. A key finding: “The US federal government responded unequally to the three hurricanes, spending more money and resources more expediently for Harvey and Irma compared with Maria, ultimately detrimental to Puerto Rico with probable effects on long-term health and other inequities.”

Nine days after Hurricanes Harvey and Irma hit, survivors in Texas and Florida had received nearly $100 million per state. In the same time frame, Puerto Rico’s survivors of Hurricane Maria had received just over $6 million in total. Two months later, Texas and Florida had received about $1 billion each. Puerto Rico didn’t receive that amount of funding for two more months: four months after the hurricane.

A similar level of disparity can be seen in the number of federal personnel at the disaster sites. In Puerto Rico, where destruction was severe and resources limited in comparison with the States, the number of people provided was smaller than in the States.

There were both direct and indirect deaths from all three hurricanes. In the wake of Hurricane Irma, 14 people died when an air conditioner in a nursing home failed. Some individuals died because they could not get necessary medical services after Hurricane Harvey. There were about 100 deaths from each of those hurricanes in the States.

Deaths in the few months after Hurricane Maria totaled about 3,000. It is likely that deaths from lack of electricity, access to health care, and clean water continued in later months as the Island worked to restore power and other basic services across the Island. Full restoration of basic services took more than a year. It is likely that the difference in federal response contributed to the great difference in the death tolls among the storms.

Why was the response so different?

The researchers listed a number of possible reasons for the different levels of response. The States might have been easier to reach, geographically. They certainly had stronger infrastructure going into the 2017 hurricane season. The researchers mentioned the fact that Americans didn’t generally realize that Puerto Ricans were citizens of the United States. They considered a number of factors ranging from attitudes to geography.  “However,” they concluded, “what cannot be contested is that the responses were in fact different across critical time points, and these differences have serious consequences for acute and long-term health outcomes and recovery efforts.”

Dr. Greer identified the problem as “a reminder of the penalties of not being fully represented in federal politics.” Puerto Rico is represented by one Resident Commissioner with a purely symbolic vote in Congress. Without Senators and voting members of Congress to stand up for her, Puerto Rico does not have the power of a State. Congress has the freedom to treat Puerto Rico differently from a State.

Inequity in Medicaid, nutrition assistance, and tax credits like EITC which are designed to combat poverty have ongoing effects on the health of thousands of people living in Puerto Rico. Inequities like these, along with the strikingly unequal disaster recovery support, demonstrate why democracy is indeed a public health policy.

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