{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T14:27:31Z","timestamp":1785421651834,"version":"3.56.0"},"reference-count":23,"publisher":"Cambridge University Press (CUP)","license":[{"start":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T00:00:00Z","timestamp":1776384000000},"content-version":"unspecified","delay-in-days":106,"URL":"https:\/\/www.cambridge.org\/core\/terms"}],"funder":[{"DOI":"10.13039\/100008618","name":"Natural Hazards Center, University of Colorado Boulder","doi-asserted-by":"publisher","award":["null"],"award-info":[{"award-number":["null"]}],"id":[{"id":"10.13039\/100008618","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Disaster med. public health prep."],"published-print":{"date-parts":[[2026]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec id=\"S1935789326103462_sec1\">\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To examine systemic challenges to health system resilience in Puerto Rico following Hurricane Maria, focusing on resource, management, and policy domains.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S1935789326103462_sec2\" sec-type=\"methods\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Semi-structured interviews (n = 62) were conducted from January to April 2023 with health care professionals, patients, community leaders, nonprofits, and government stakeholders using purposive sampling. Interviews were conducted in Spanish, transcribed, translated, and thematically analyzed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S1935789326103462_sec3\" sec-type=\"results\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Resource failures centered on prolonged power outages (mean 62.7 days; up to 300 days), which cascaded into water, transport, and communication breakdowns. These disruptions endangered patients through interrupted surgeries, inoperable imaging, oxygen shortages, and infection control failures. Management challenges included depleted stockpiles, staff burnout, and workforce migration, which extended wait times to 6-8 months. Coordination was inconsistent, with duplication of aid in some areas and neglect in others, while top-down governance slowed response. Policy constraints compounded vulnerabilities: health insurance pre-authorizations delayed urgent care, capped Medicaid funds, and lack of federal parity, limited preparedness, and centralized aid distribution left rural communities underserved.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S1935789326103462_sec4\" sec-type=\"conclusions\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Puerto Rico\u2019s health system resilience was undermined by interdependent failures across infrastructure, management, and policy. Building resilience will require investment in decentralized power, reforms to emergency insurance protocols, stronger inter-agency coordination, and equitable federal financing to ensure preparedness for future climate-related disasters.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1017\/dmp.2026.10346","type":"journal-article","created":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T08:47:45Z","timestamp":1776415665000},"source":"Crossref","is-referenced-by-count":0,"title":["Disaster Impact and Health System Resilience: A Case Study of Hurricane Maria in Puerto Rico"],"prefix":"10.1017","volume":"20","author":[{"given":"Pallab","family":"Mozumder","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/02gz6gg07","id-type":"ROR","asserted-by":"publisher"}],"name":"Florida International University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linnette","family":"Rodriguez-Figueroa","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/00h25w961","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Puerto Rico Medical Sciences Campus"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mayra","family":"Quiles-Miranda","sequence":"additional","affiliation":[{"name":"The Puerto Rico Medical Services Administration"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barsha","family":"Manandhar","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05tc5bm31","id-type":"ROR","asserted-by":"publisher"}],"name":"Florida Gulf Coast University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0677-2717","authenticated-orcid":false,"given":"Sisi","family":"Meng","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/00mkhxb43","id-type":"ROR","asserted-by":"publisher"}],"name":"Cornell University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nafisa","family":"Halim","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05qwgg493","id-type":"ROR","asserted-by":"publisher"}],"name":"Boston University"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"56","published-online":{"date-parts":[[2026,4,17]]},"reference":[{"key":"S1935789326103462_r14","first-page":"288","volume-title":"Natural Hazards Center Quick Response Grant Report Series","author":"Niles","year":"2019"},{"key":"S1935789326103462_r9","unstructured":"9. Mozumder, P , Rodriguez-Figueroa, L , Quiles-Miranda, M , et al. Assessing Impacts of Hurricane Maria for Promoting Healthcare Resilience in Puerto Rico. 2023. Accessed January 21, 2024. https:\/\/hazards.colorado.edu\/public-health-disaster-research\/assessing-impacts-of-hurricane-maria-for-promoting-healthcare-resilience-in-puerto-rico"},{"key":"S1935789326103462_r15","doi-asserted-by":"publisher","DOI":"10.1186\/s41256-021-00228-w"},{"key":"S1935789326103462_r3","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.j2323"},{"key":"S1935789326103462_r17","doi-asserted-by":"publisher","DOI":"10.1257\/pandp.20211116"},{"key":"S1935789326103462_r18","doi-asserted-by":"publisher","DOI":"10.15171\/ijhpm.2017.36"},{"key":"S1935789326103462_r4","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-13-450"},{"key":"S1935789326103462_r5","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2019.112367"},{"key":"S1935789326103462_r7","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2017.304198"},{"key":"S1935789326103462_r6","doi-asserted-by":"publisher","DOI":"10.1017\/dmp.2022.272"},{"key":"S1935789326103462_r12","doi-asserted-by":"crossref","first-page":"E305","DOI":"10.1001\/amajethics.2022.305","article-title":"How is colonialism a sociostructural determinant of health in Puerto Rico?","volume":"24","author":"Ramos","year":"2022","journal-title":"AMA J Ethics."},{"key":"S1935789326103462_r8","unstructured":"8. Perreira, K , Peters, R , Lallemand, N , et al. Puerto Rico Health Care Infrastructure Assessment: Site Visit Report. Urban Institute; 2017. Accessed August 3, 2023. https:\/\/www.urban.org\/sites\/default\/files\/publication\/90446\/2001050-puerto-rico-health-care-infratructure-assessment-site-visit-report_1.pdf"},{"key":"S1935789326103462_r10","doi-asserted-by":"publisher","DOI":"10.1080\/09581596.2021.1998376"},{"key":"S1935789326103462_r20","unstructured":"20. World Health Organization. COVID-19: Operational Guidance for Maintaining Essential Health Services During an Outbreak: Interim Guidance. Published March 25, 2020. Accessed June 21, 2025. https:\/\/iris.who.int\/handle\/10665\/331561"},{"key":"S1935789326103462_r22","doi-asserted-by":"publisher","DOI":"10.1017\/dmp.2016.195"},{"key":"S1935789326103462_r2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(15)60755-3"},{"key":"S1935789326103462_r23","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czx183"},{"key":"S1935789326103462_r21","doi-asserted-by":"publisher","DOI":"10.1193\/121116eqs231m"},{"key":"S1935789326103462_r16","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa1803972"},{"key":"S1935789326103462_r1","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.14.149278"},{"key":"S1935789326103462_r19","unstructured":"19. Chandra, A , Marsh, T , Madrigano, J , et al. Health and Social Services in Puerto Rico Before and After Hurricane Maria. RAND. January 1, 2020. Accessed October 14, 2024. https:\/\/www.rand.org\/pubs\/research_reports\/RR2603.html"},{"key":"S1935789326103462_r11","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2020.305814"},{"key":"S1935789326103462_r13","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2017.304138"}],"container-title":["Disaster Medicine and Public Health Preparedness"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.cambridge.org\/core\/services\/aop-cambridge-core\/content\/view\/S1935789326103462","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T08:47:51Z","timestamp":1776415671000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.cambridge.org\/core\/product\/identifier\/S1935789326103462\/type\/journal_article"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026]]},"references-count":23,"alternative-id":["S1935789326103462"],"URL":"https:\/\/doi.org\/10.1017\/dmp.2026.10346","relation":{},"ISSN":["1935-7893","1938-744X"],"issn-type":[{"value":"1935-7893","type":"print"},{"value":"1938-744X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026]]},"article-number":"e91"}}