Learning from Recent Disasters: Three Lessons for Public Health.

In recent months, the US has endured a seemingly unending series of natural and human-made disasters. Hurricane Harvey brought widespread flooding to Texas; Hurricane Irma swept though Miami; and Hurricane Maria, abetted by a lackluster federal response, created a humanitarian crisis in Puerto Rico, where millions of US citizens remain without adequate food, water, and electricity. The catastrophe in Puerto Rico, in particular, is still very much an ongoing tragedy, worsened by the Trump administration’s negligence. In The New York Times, Eric Klinenberg recently outlined how conditions on the ground have compounded the disaster in Puerto Rico, producing a death toll that is likely far higher than early estimates. In addition to these shocks, we have seen wildfires in Northern California, the deadliest mass shooting in our country’s history in Las Vegas, and another mass shooting in Texas—the deadliest that has ever taken place inside an American church. Outside the US, an earthquake on the Iraq–Iran border last week killed at least 530 people. While we are still learning about this disaster, the collapse of low-income housing units appears to have contributed much to the toll of death and injury, proving once more that, when disasters strike, it is always the poor who are at greatest risk.

The pace of these events can generate a feeling that the world is, in some fundamental way, spinning beyond our capacity to make a difference. Yet when we look at underlying causes—the institutional failures, political negligence, and broader structural liabilities that facilitated these disasters—it becomes clear that such events are not inevitable, and that there is much we can do to prevent them from causing widespread harm. We cannot stop hurricanes from forming or disturbed individuals from wishing to commit crimes, but we can take steps to make populations more resilient in the face of catastrophe, and to mitigate the force of disasters when they happen. Recent events also challenge us to look beyond disasters to see that we must invest in health as a public good—shoring up the policies and institutions that create healthy societies—if we are to cultivate true resilience in populations. This agitates for shifting focus away from solutions tailored solely for the benefit of individuals and towards measures that contribute to our collective health. With this in mind, for today’s note I would like to suggest three key takeaways from recent months, to inform thinking about how we might achieve the goal of healthier, less vulnerable populations.

Disasters can feel sudden, but their roots grow slowly and in plain sight.

Storms, shootings, and wildfires can appear, on the surface, as examples of random, unexpected hardship. Yet all occur within a specific context. If this context is characterized by poverty, marginalization, and political negligence, it can make disasters far more destructive than they otherwise would have been. This has been the case in Puerto Rico. President Trump has called attention to the economic and infrastructural problems that plagued the island in the years before Hurricane Maria hit. While the President’s response to Puerto Rico’s present need has been inadequate at best, and cruel at worst, he was correct in spotlighting these underlying factors. Economic difficulty and a weak infrastructure can indeed exacerbate disasters, making a bad situation catastrophic.

It is also important to note that such challenges do not develop overnight. It takes years for economies to fail and infrastructures to erode. The fact that Puerto Rico’s problems were dismissed for so long both heightens the current tragedy and suggests, hearteningly, that by addressing these challenges in other struggling regions we can build population-level resilience between now and the next disaster. Gun control is another area where the tragedy is made worse for being for so predictable. The data tell us that gun control laws can reduce the likelihood of shootings. Rates of firearm-related intimate partner homicide, for example, were 14 percent lower in states that passed laws requiring individuals subject to intimate partner violence-related restraining orders to relinquish their guns. Yet as long as we refuse to act on these data at the national level, we can expect more mass shootings. When these events occur, we are understandably appalled, but we should not be surprised. The upshot of a disaster may happen in an instant, but its origins often unfold over years of willful neglect.

We prioritize the well-being of individuals over the health of populations. This ill serves us when disaster strikes.

Why do we frequently ignore the foundational determinants of health, waiting until moments of acute crisis to address them? In the US, this tendency is part of a broader pattern of focusing on what is good for the individual over what benefits populations, a trend well-illustrated by our investment in health. The US spends more on health than any other country in the world, yet our health outcomes remain mediocre. This is because the vast majority of our spending is on curative care geared towards treating individuals, at the expense of investing in the social, economic, and environmental conditions that shape population health. We can, for example, provide quality treatment for asthma. Yet we have proven less adept at curbing the trend of deregulation that allows companies to pollute the air. We can perform cutting-edge surgeries to ease the effects of heart disease. But when it comes to reckoning with the conditions of poverty and the easy accessibility of sugar-sweetened beverages—both of which contribute much to the burden of obesity in this country—we fall short. Because of the tremendous advances we have made in the realm of curative care, we are too often willing to withhold investment in population health, secure in the knowledge that we, personally, can access treatment if we need it. When disaster strikes, it exposes the hollowness of this thinking, reminding us that our health is tied to the physical and social structures around us, that no one “is an island,” and that to be truly healthy means being part of a society that embraces health as a collective value.

The best action we can take to prepare for disasters, both natural and human-made, is to invest in health as a public good.

As much as recent events teach us about anticipating and responding to disasters, they also carry broader implications for how we promote well-being in our society. I have written previously about public goods, which are defined by economists as goods or services “of which anyone can consume as much as desired without reducing the amount available for others.” They are a product of our investment in the structures and policies that ensure all can live healthy, productive lives. Clean air, national security, and—as US public opinion increasingly reflects—health care are all examples of public goods. The disasters of recent months represent a fundamental disinvestment in public goods, a trend that has left us exposed to much preventable hazard. We could, for example, regulate carbon emissions to help mitigate climate change and, potentially, the extreme weather it can lead to. We could fight poverty using measures like an expanded Earned Income Tax Credit or a livable $15 minimum wage, to make populations less vulnerable in the face of storms like Hurricane Maria. Finally, we could reduce the likelihood of mass shootings by enacting common-sense solutions like universal background checks and ballistic fingerprinting. All of these steps represent an investment in public goods.

These observations challenge the view that “nothing can be done” to protect populations from disasters. The idea that routine calamities are inevitable and to be accepted, or even that they are the price of our freedom as Americans, is a disturbing one, yet it is more troubling to think that we can do something, but choose not to. The cost of recent months in lives lost, property destroyed, and societies disrupted argues that we have a responsibility to never settle for “nothing can be done.” With our collective vulnerability exposed, we should respond with collective investment in improving the institutions, conditions, and policies that shape health in both our day-to-day lives and when disasters put our resilience to the test.

I hope everyone has a terrific week. Until next week.

Warm Regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful to Eric DelGizzo for his contributions to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/