The Public Health Consequences of Compounding Disasters and Colonialism in Puerto Rico: A Mixed-Methods Investigation

Abstract

In recent decades, the ongoing climate crisis has disproportionately impacted historically marginalized populations globally through environmental hazards and disasters. Understanding the health impacts of multiple disaster exposure has become increasingly critical as disasters associated with climate change and environmental hazards are increasing in frequency, intensity, and duration, and can precede or co-occur with other disasters such as pandemics, oil spills, biological attacks, and other natural and/or human-made disasters. The U.S. territory of Puerto Rico provides a unique opportunity to examine this relationship since it has been plagued by multiple disaster events in the past decade–including a category five hurricane, earthquakes, and the COVID-19 pandemic—and its political relationship with the United States can be considered colonial. Importantly, colonialism could be characterized as a social determinant of health, but it has been scarcely examined as such in epidemiologic literature. This dissertation considers social, occupational, and environmental factors and explores the relationship between multiple disaster exposure, physical, mental, and reproductive health outcomes, and the role of colonialism in modifying this relationship. Aim 1 explored associations between multiple disaster exposure and self-reported physical health, mental health, and health behaviors, and identified effect modifiers, among Puerto Rican participants from the Behavioral Risk Factor Surveillance System from 2017 to 2021. Overall, we found higher levels of poor physical and mental health, substance use, and self-reported perceptions of health in disaster periods compared to pre-disaster levels. Further, sociodemographic characteristics including sex, income, education, and employment status, modified the relationship between exposure and outcome. However, the direction and magnitude of these associations varied by disaster period. Aim 2 explored multiple disaster exposure and pregnancy-related maternal and newborn health outcomes using United States official vital records from 2017 to 2021, focusing on Puerto Rico and using Texas and Florida as comparisons to consider the role of colonialism. Overall, adverse maternal health outcomes (i.e., gestational hypertension, gestational diabetes, and excessive weight gain) were higher among Puerto Rican women in disaster periods compared to pre-disaster levels, and colonialism modified this relationship. Newborn health outcomes (i.e., preterm birth and low birthweight) were not similarly elevated in disaster periods, but this association may be underestimated due to live birth bias. Aim 3 contextualized the results from the first two aims through in-depth interviews with 30 participants in Puerto Rico. We found considerable geographic-level differences in terms of health trajectories and disaster experience, a significant toll on mental and behavioral health, widespread lack of healthcare access, worsening financial conditions over time, complications with prenatal care and worsening reproductive health, a sense of hopelessness about prosperity and quality of life, and participants feeling discouraged from having children. These results helped us identify future research to fill gaps and interpret epidemiology findings. Altogether, the results of this dissertation suggest widespread adverse health impacts from multiple disaster exposure in Puerto Rico and socio-structural inequities due to colonialism, persisting socioeconomic inequity, and governmental mismanagement of pre- and post- disaster conditions. Findings highlight the need for improved disaster preparedness and response, investment in more resilient climate and disaster-ready infrastructure, early disaster interventions to increase access to mental healthcare, and other policies and interventions to address financial inequities, improve quality of life, and reduce the impacts of disasters and colonialism.