Social Vulnerability and the Role of Puerto Rico’s Healthcare Workers after Hurricane Maria

Publication Date: 2019

Abstract

Hurricane Maria was one of the most devastating storms in United States history. The tremendous force of the hurricane, along with the associated wind, rain, flooding, and critical infrastructure damage, caused incredible disruption to lives and livelihoods. Our study uses interview and observation data with healthcare workers across Puerto Rico to better understand what kind of impacts the hurricane had on people’s health, and who was most impacted. We sought to understand how healthcare workers responded to the crisis in order to reach communities in need. Our study highlights how and why people with chronic health conditions, those who were economically disadvantaged, rural populations, and older populations were particularly vulnerable to the health impacts of the storm and massive, extended disruptions to key infrastructure. We also explore how Puerto Rico’s colonial relationship to the United States, migration patterns, economic recession, and underfunding of health care services contributed to health vulnerabilities. Despite severely compromised health facilities and services across Puerto Rico, the healthcare workers that participated in our study accomplished incredible feats in their efforts to reach people in need. Flexibility in roles and local knowledge of communities were key for being able to conduct medical outreach and to know what kinds of services to provide.

One of the Worst Disasters in U.S. History

In September 2017, Hurricane Maria devastated Puerto Rico, in what is now regarded as one of the worst natural disasters in U.S. history (Branigan 2018¹). While there have been several different reports of the death toll (Robles et al. 2017², Santos-Lozada & Howard 2018³, Kishore et al. 2018⁴, Andrade et al. 2018⁵), in August 2018, the government of Puerto Rico announced a new report that raised the official death toll from 64 deaths to 2,975 deaths, making it one of the United States’ deadliest disasters (Santiago et al. 2018⁶). Hurricane Maria struck Puerto Rico as a Category 4 hurricane with sustained winds as high as 155 miles per hour, causing loss of electricity, cell service, damage to buildings, roads, and other critical infrastructure such as water supplies across the entire island archipelago that lasted for months after the hurricane (Schwartz 2018⁷). According to a report in the New England Journal of Medicine (NEJM), between the time when Hurricane Maria hit and the end of 2017 households went, on average, three months without electricity, more than two months without water, and more than one month without cellular service (Kishore et al. 2018).

While the immediate damage from the storm itself was immense, the extended effects of the loss of power, water, and communication were also devasting, particularly as it relates to people’s access to healthcare services. The tremendous and extended disruption to these services not only affected households, but also damaged key medical facilities across the island (Michaud & Kates 2017⁸). According to the same NEJM report, over 30 percent of Puerto Rican households reported problems accessing medical care after the hurricane, including the inability to get medications, closed medical facilities, and not being able to call 911 services (Kishore et al. 2018). Close to one third of respondents attributed deaths of household members to disruption in medical care (Kishore et al. 2018). According to a New York Times report, in the first few months after Hurricane Maria there was a 47 percent increase in deaths due to sepsis, a 45 percent increase in deaths from pneumonia, and a 31 percent increase in deaths due to diabetes, indicating a high rise in deaths that might typically be preventable with regular medical care (Robles et al. 2017).

These reports highlight the fact that the extended effects of the slow restoration of basic power and transportation following Hurricane Maria led to large-scale damage and disruption of health care services. However, these findings do not provide information on the ways in which social structures contributed to the distribution of disaster impacts. The disruption of medical services affected all of Puerto Rico, but it did not affect everyone equally. For some, the disruption to medical services was more severe, and the consequences on their medical conditions more dire. A wealth of previous research has shown that disasters are not “natural,” and that impacts are shaped by social structures and inequalities, including class, race, gender, and geographic location (e.g. Klinenberg 2002⁹, Cutter et al. 2003¹⁰, Fothergill & Peek 2004¹¹, Enarson et al. 2007¹², Tierney 2015¹³). However, less is known about how these specific types of social structures impacted health and mortality in Puerto Rico following Hurricane Maria and the underlying causes and processes through which these distinct populations were more affected by the disaster impacts. As one of the deadliest disasters in U.S. history (Branigan 2018) and as the largest blackout in U.S. history (Houser & Marsters 2018¹⁴), it merits examining and understanding the broader social factors that contributed to the large number of hurricane-related deaths that occurred immediately after and for months following the storm (Kishore et al. 2018, Andrade et al. 2018).

Furthermore, while existing reports document that healthcare access was damaged and health facilities were compromised, they do not tell us much about how healthcare workers responded to the crisis in order to reach vulnerable populations and meet medical needs after the hurricane. There is little known research about what this experience was like for healthcare workers as they struggled to meet medical demands within a severely damaged and resource-limited environment. Since healthcare workers interacted closely with people with medical conditions, they are able to provide rich information about what kinds of health challenges people faced after Hurricane Maria. While healthcare workers were not able to reach everyone in need, they nonetheless serve as key informants for understanding the medical needs of community members and the complexities and challenges of delivering health care within a severely compromised medical services context. This is particularly important for understanding how complex, extended disasters with disruptions to communication, electricity, and transit impact both population health and health care systems.

In this research study, we aim to understand:

1. What were the predominant health issues after Hurricane Maria, and how were these challenges shaped by social structures?

2. What kind of difficulties did healthcare workers face in delivering health care after the hurricane and how did they address these challenges?

Methods

This research relies on interview and observation data collected in June of 2018. This report reflects the initial phase of data collection, as funded by the Natural Hazards Center Quick Response Grant Program. Data includes interviews with healthcare workers and observations of healthcare clinics in Puerto Rico.

Interviews were conducted with 30 healthcare workers over the course of 19 separate interviews. Interviews averaged 1.25 hours in length and were audio recorded (with the exception of one interview in which the two respondents requested not to be audio recorded). Eleven of these interviews were individual interviews, and eight were group interviews (typically two person-interviews). Extensive notes were taken both during and after all interviews. Respondents included a range of professionals including medical directors, clinic CEOs, doctors, public health workers and academics, mental health specialists, and community outreach healthcare workers in non-profit, government-funded, and university-related health organizations. The names and organizations of each respondent were anonymized for confidentiality.

Interviews were semi-structured, focusing on questions related to what healthcare workers experienced and how they responded to the crisis in order to provide medical care to community members. We asked healthcare providers how their healthcare interventions had changed due to the hurricane, and what kind of challenges patients were experiencing in arranging for their healthcare needs in the post-disaster environment. These workers are not able speak to the experiences of all people who suffered from morbidity or mortality after the hurricane, nor to all healthcare experiences. Nonetheless, healthcare workers are able to interpret general trends in health challenges, as well as describe the specific difficulties that they encountered when treating patients.

The semi-structured format of the interviews also allowed for the respondent to elaborate or direct the conversation if there were particularly impactful and important aspects about their experiences during and after the hurricane that they were interested in sharing. This interview format was also valuable because, due to the often difficult and emotional experience of the hurricane, it was important for the respondent to be able to have control over what kinds of questions they wanted to address.

Observation data was also collected at each clinic. For patient privacy, close observations of client-provider interactions were not observed; however, general observations about clinic size, location, neighborhood characteristics, appearance, and general impressions regarding clientele (i.e. age, number of people in lobby, etc.) were observed at each clinic and healthcare organization site. Observations and notes were also taken daily to note signs of hurricane damage (e.g. downed powerlines, damaged buildings, blue tarp rooftops), cultural messages regarding the hurricane (e.g. graffiti, murals, signs or posters), and other notable events or signs of the hurricane impacts (e.g. a recurrent radio message for suicide prevention).

Because of the varied geographies of Puerto Rico (including isolated central mountainous regions), we sought to interview healthcare workers that worked across the island. Our respondents were located in or were actively engaged in medical aid outreach in every major region of Puerto Rico, including the Metro region, Northern, Eastern, Southern, Western, and Central regions of Puerto Rico. Many healthcare workers were involved in outreach work outside of the clinic, and were therefore able to speak about the healthcare challenges both within the clinic and also outside in the communities that they served throughout Puerto Rico.

Preliminary Findings

Findings for this report focus on preliminary themes identified during field work conducted in June 2018. We focus our discussion here on the key themes that emerged during our time in the field and initial analysis of interview and observation data.

While we outline specific separate challenges below, it is important to keep in mind that many people faced intersecting factors that created increased vulnerability to harm, which Fothergill and Peek (2015)¹⁵ have described as “cumulative vulnerabilities.” For example, a person might have a chronic health condition, low socioeconomic status, and also live in an isolated area, which all together could work to cumulatively increase their risk of illness and mortality following the hurricane.

Poverty and Health Inequality

Puerto Rico has a very high poverty rate, with just more than 45 percent of Puerto Ricans living below the federal poverty level, a rate that is drastically higher than the U.S. average of around 15 percent (U.S. Census Bureau 2016¹⁶). According to an August 2018 George Washington University report on the hurricane death toll, the poorest counties in Puerto Rico experienced continuously increasing hurricane-related deaths each month between September 2017 and January 2018; whereas counties with middle and higher economic development had decreasing hurricane-related deaths after October 2017 (Andrade et al. 2018). This indicates that people living in poorer counties experienced greater hurricane-related fatalities that occurred for a much longer time after the storm. Our respondents explained that having fewer economic resources affected people in many ways, from difficulty purchasing food and medication to living in substandard housing that was continually exposed to flooding and mold.

For many Puerto Ricans who did not have cash on hand, or who received government food assistance through the Electronic Benefits Transfer (EBT) system, it was difficult to buy anything after the hurricane. In the wake of large-scale power outages and extended time periods with no electricity, many people could not use their electronic government assistance cards to purchase basic food supplies. This resulted disproportionate access to proper nutrition for lower-income people, which for many was key to managing their health conditions. One doctor described going to do outreach in a more rural community, where she was surprised to find that, unlike grocery stores in the city, which were stripped bare of food items as soon as they arrived, this grocery store was stocked:

“In addition to no communication, no diesel, and no food, it was also a cash only economy. Banks were shut down for a month—more than a month. Unless you had cash that you were able to get beforehand, there was not a way to buy anything. So a lot of people suffered. I went to [a rural town], which is up in the mountains, and I happened to stop at the grocery store, and there was stuff [food]. The [city] grocery stores were completely empty, but they had stuff. And I asked, why? Because people in [the rural town] do not have cash to buy it. People were hungry and there was a grocery store, but a lot of people are on welfare, and that money is on a card and there was no way to swipe it.”

Furthermore, many people who could not buy food had to rely on canned food and emergency processed meals with high fat, sugar, and sodium content that can exacerbate health conditions like high blood pressure and diabetes. One public health worker described that these emergency meals posed a health threat to people with diabetes:

“I remember the military boxes that FEMA gave people. I was like, ‘Do they want to kill us?’ Snickers, M&M’s, Skittles, danishes. Juices that were like 5 percent juice. . . For a person with diabetes, with dialysis [that’s dangerous] . . . But if they don’t have anything else to eat, how can you tell them, ‘Do not eat this,’ if you are not able to give them something better? . . . I worked with a nutritionist and we developed these emergency menus: ‘If you are going to eat processed chicken, you can mix it with [canned] vegetables, but make sure that you wash the vegetables so that you don’t eat all of the salt.’ . . . We decided to do that because people were saying, ‘I am worried because I have diabetes, but I don’t have anything else to eat.’

In this case, the public health worker had to alter the emergency rations in order to make them less risky for people with diabetes and high blood pressure. This intersection of lack of access to adequate nutrition contributed to elevated risk of serious medical complications that disproportionately impacted people with less economic and material resources.

In addition, many people of lower economic status could not afford to repair damages to their houses were continually exposed to rain, flooding, mold, and mosquitos from standing water. Having fewer economic resources also inhibited ability to access medications and increased risk of repeated and chronic exposure to health risks after the storm. Doctors described treating patients for medical conditions such as respiratory and skin diseases due to mold spores from ongoing exposure to rain and flooding and patients going for weeks or months without taking critical medications. One doctor in a rural, economically depressed area described the concerns that continued to impact patients eight months after the storm:

“Most of the people that come to the clinic come exhibiting the same signs. People are breathing the spores of this [mold] fungus, and the spores are now also causing skin rashes . . . A lot of people [from outside of Puerto Rico] don’t realize [this] because they come to Puerto Rico and they go to the tourist area, and they see that the power has been restored, and they don’t really see the devastation of what has happened in populations like this that are completely isolated. We have seen people that have not taken their blood pressure medication; their diabetes medication for six or seven weeks.”

This doctor highlighted how the intersecting issues of lack of access to medication, as well as continued to exposure to flooding and mold impacted health concerns in this rural, economically depressed area. Respondents also cited that barriers such lack of transportation to clinics and economic constraints contributed to difficulties accessing medication. This contributed to how people with less economic resources experienced greater exposure to medical concerns, as well as greater challenges accessing medical care.

Geographic Isolation and Effects on Health

Geographic isolation and delay of services to rural areas also increased health vulnerabilities to those living in rural areas. Issues related to geography were very apparent from our own experiences collecting data in these isolated areas of Puerto Rico. For example, visiting a clinic for observations in the central mountainous regions required allocating more extensive travel time because one of the main roads was still impassible eight months after the hurricane.

Furthermore, the demands this isolation placed on medical professionals working in remote locations were strongly felt while conducting fieldwork in a rural community. An interview was cut short when the respondent had to address an urgent concern with a patient because the respondent was one of only a few doctors in the clinic and surrounding area. Data noting how many clinics and pharmacies were closed because of the storm and for how long is not available; however, we consistently heard from healthcare workers in various locations across the island that they were the only clinic or pharmacy open in the area, or that they were one of just a few medical facilities open.

One medical clinic located in the mountains described how they had to operate their ER for months without a regular supply of water. The director described that because their clinic was the only one serving the surrounding communities, he felt obligated to keep the clinic operational.

“One of the greatest challenges was to function with no water, or to close the facility. Two physicians said to me, the environment [could cause] an infection. And I said, ‘Okay, what do you want? To close? What will happen with the community? They won’t have a [medical] center open’ . . . We purchased storage tanks for water and diesel. And we purchased water from the city and brought it here in trucks. So that was how we kept this place running without water. And it took at least two months to get water restored. And when it was restored there would be water for one or two days, and then it would be out for two.”.

In this case, the director had to make a difficult decision to choose to continue to operate the clinic, even in a substandard environment, because if they were to close there would be no medical facility to serve the surrounding mountain communities.

The increased remoteness brought about by damaged roads and lack of transportation access, combined with the widespread closure of smaller clinics, served to further contribute to the inadequate medical and emergency care available to people in isolated areas. As was described by another respondent, “The reality of our community [is that] we are alone. We are by ourselves.”

Migration Patterns, Social Networks, and Aging

Elderly adults often faced the intersecting challenges of chronic health conditions and social isolation. A common theme that healthcare workers reported is that when doing outreach in the community, many elderly adults lived alone because family members had migrated to the United States. Due in large part to the drastic economic recession, Puerto Rico has experienced a large population loss in the last several years (Krogstad 2016¹⁷). According to the U.S. Census Bureau, the population declined by more than 10 percent between 2010-2017 (U.S. Census Bureau 2017¹⁸). After the hurricane, it was estimated that an additional 8 percent of the remaining population was displaced and migrated out of Puerto Rico (Andrade et al. 2018). While the important role the Puerto Rican diaspora has played in organizing support for Puerto Rico should not be understated, it is important to recognize that the large population loss in recent years may have impacted the family support networks that previously existed on the island. According to the 2016 American Community Survey, close to 40 percent of adults over age 65 in Puerto Rico live alone. As one doctor described, “We encountered families where people were disabled, especially the elderly, living alone, without any kind of help.”

Even those that lived with partners could still have limited social networks. One medical director described how her clinic’s outreach team found an isolated elderly couple without anyone else to help them after the storm destroyed much of their house:

“There was an elderly couple who were sheltering in a tiny corner of the house, because the whole house was without a roof. . . They were [stuck] there because didn’t have any transportation or anything. They were all alone.”

Migration patterns and disruption to social networks, as well as chronic health conditions created additional health challenges for many older Puerto Ricans after the storm. For healthcare workers we interviewed, this often meant that they lacked family members who could take them to medical facilities, or to check in on them after the storm. Given the widespread loss of cellular communication and power, in-person meetings were essential to check on the health of a family member.

Economic Recession and Unequal Funding of the Healthcare System

While there were certainly immediate stressors on both the healthcare system as well as the health of individuals and communities because of the effects of the hurricane, there were many additional underlying structural factors that also contributed to the massively damaging impacts of the storm. As has been discussed by others, the more than ten-year economic recession brought about significant disinvestment in public social services, which had devastating consequences on community vulnerability (Klein 2018¹⁹). For example, the controversial privatization of the healthcare system and managed care model has also been cited as having a debilitating effect on the healthcare infrastructure of Puerto Rico (Perreira et al. 2017²⁰). Furthermore, 72 out of 78 counties in Puerto Rico are considered to be medically underserved (Perreira et al. 2017). And despite the fact that nearly half the population relies on Medicaid health insurance, Medicaid services in Puerto Rico continue to be underfunded by the U.S. federal government (Merling & Johnston 2017²¹).

Several respondents stated very directly that they believed that the colonial relationship to the United States was critical in shaping difficulties, including barriers to accessing key medical supplies, food, and water, as well as a feeling that they were treated as “second-class citizens.” As one respondent expressed:

“The word that I will use in neglect. The federal government showed neglect. They didn’t put a top priority for us. . . And we are not treated equally. As a Puerto Rican, I really hurt. . . Unless we change the system, Puerto Rico will never recuperate. Puerto Rico cannot continue being a colony like it is. No way. It is not equal treatment.

This emotional response represents the respondent’s view that the colonial status of Puerto Rico was a central factor in producing a deficient response to the hurricane. In addition, many respondents expressed frustration with the Puerto Rican government, as well as with the federal disaster response, stating that it was incredibly slow and provided inadequate support. Health care workers explained how they had to coordinate with other organizations and partners in order to obtain medical supplies and donations to provide care to patients in need.

Outreach to Isolated and Vulnerable Populations

There were clearly many structural factors that shaped health inequalities, and healthcare workers had to work within and overcome these constraints to reach vulnerable populations and provide medical services to those in need. One of the key aspects of healthcare worker response was outreach in the community. Almost all of the healthcare organizations provided medical outreach services in the community, including setting up mobile clinics and travelling door-to-door, which was essential for reaching people who were not able to make it into the clinic itself. Many of the clinics already had some established outreach in the neighboring communities, but this was expanded and extended after the hurricane.

Collaboration with community leaders, mayors, and local people familiar with the community was essential for identifying where people needed assistance, and how to get to them. As one healthcare worker explained:

“We have a team that contacts the leader of the community, who…sees how many people are homebound. We find out what their needs are so when the nurse and the doctor arrive in the community, they know where to go.”

Collaboration and local knowledge was key to assessing the needs of the community and delivering necessary medical services. Workers described going door-to-door to assist people in their homes, as well as establishing mobile clinics in central locations in the community.

The need for these services continued for many months after the hurricane. When we conducted fieldwork in June 2018, many outreach clinics were still operating in communities where adequate healthcare services had yet to be established. The outreach groups were also interdisciplinary teams, so that they were able to fully assist people with diverse needs. One director described the scene at one of the mobile clinics:

[There were] hundreds and hundreds of people that [were] standing in line waiting to be seen by our doctors . . . We had our social workers and our physicians and our psychologists. And they would do referrals. So, if somebody comes in for asthma, but the physician feels like they need to be seen by a psychologist or a psychiatrist, we also had the team of people there to help. We had a social worker there to help if they are homeless. If they need any kind of documentation filled out, our social worker would attend to that. And this went on forever and ever and ever.

One of the aspects of the response that stood out during our field work was how long the outreach continued, and how much ongoing need for medical services and support there were in communities across Puerto Rico.

Providing Emotional Support to the Community

Healthcare workers also talked about the importance of providing emotional support to community members. Many described how people just needed someone to talk to and to listen to them after the intense emotional distress of the storm, both immediately and in the months following the event. One nonprofit worker described how, “we have people that are crying telling their stories, seven months later after the hurricane.” Therefore, it became critical that healthcare workers not only bring medical services to communities, but that they were also prepared to offer emotional support. This was especially important because of the large number of mental health challenges people faced after the hurricane. According to one medical director, after the hurricane two of the top five most frequently diagnoses in the clinic’s ER were depression and anxiety, which wasn’t the case before the storm.

In our research we found that, despite personal challenges and suffering, many healthcare workers dedicated themselves to incredible service to others during this time. Many of the healthcare workers had lost their houses or had friends or family members who died as a result of the storm. Several respondents spoke about having slept for weeks or even months at the clinic or health facility so that they would be able to work longer hours. Others described waking up at dawn and not returning from work until close to midnight, or working double shifts at multiple healthcare sites. Many also discussed how having some kind of purpose and role in helping their community was also incredibly important to them, despite the emotional and physical hardship that this entailed. However, rather than dwelling on personal sacrifices, they emphasized the importance and power of community. As one director put it:

“It is important to let you know that this [work] is not a product of just [our organization]. This is a bunch of people that want to work for Puerto Rico, and who have love in their heart.”

This collaborative sentiment was echoed by many respondents, who highlighted the importance of community, love, and Puerto Rican pride as being key social and cultural strengths in their work.

Discussion

Hurricane Maria was one of the most devastating storms in United States history. The tremendous force of the hurricane, along with the associated wind, rain, flooding, and critical infrastructure damage, caused incredible disruption to lives and livelihoods, but these effects were not experienced equally. People with chronic health conditions, those who were economically disadvantaged, and older populations were particularly vulnerable to the health impacts of the storm. In addition to the challenges brought about by the disaster, there were also larger structural issues which contributed to the overall vulnerability of community members, such as the colonial relationship to the United States, migration patterns, economic recession, and underfunding of healthcare services.

Despite the inadequate and severely compromised health facilities and services across Puerto Rico, the healthcare workers that participated in our study were working tremendously hard to try to reach people in need. This often meant taking on new roles such as becoming an outreach worker, as well as collaborating with community members and using local community knowledge to best meet people’s medical needs. Flexibility and local knowledge of communities was key for being able to conduct medical outreach and to know where to go and what kinds of services to bring.

Limitations and Future Work

It is important to note that the findings discussed in this report are preliminary, and further research and analysis is needed to make specific theoretical claims. Because interviews were conducted with a wide range of respondents in varied medical roles, this study does have certain limitations. For example, we are unable to make larger conclusions regarding the experience of all doctors or health organizations in Puerto Rico after the hurricane. Furthermore, according to our respondents, many smaller, private clinics closed after hurricane Maria because they did not have backup water supplies or generators for power. We were unable to talk with their medical professionals, who may or may not have stopped providing services after the hurricane. Further research is needed to determine what happened with these smaller clinics and medical providers. In addition, we use healthcare worker descriptions of the healthcare challenges facing communities, and we recognize that this is not always in full alignment with how community members might describe the challenges themselves. Despite these limitations, salient and recurring themes were found across different roles and positions that lend support to our analysis that these are not just unique individual experiences, but rather were patterns occurring across geographic place and healthcare positions.

There is rich theoretical work on social disparities in health and social inequality in disasters that we will draw upon in future analyses of this study and the continuation of this research. In particular, we are interested in examining more specifically how healthcare workers engage with communities in the post-disaster context, how they integrate visions of long-term recovery into their short-term response efforts, and the relationship between broader social structures impacting health outcomes and how healthcare workers define and approach their work.

Recommendations

To prepare for and mitigate damages from future hurricanes, it is important for policy makers, communities, emergency managers, disasters researchers, and healthcare workers to continue to understand and address the processes through which social inequalities are reproduced in disasters. Drawing from the preliminary results in this study, there are indications that more support is needed for medical care in rural areas, that additional support and emergency cash assistance may be necessary for low income groups, that secondary systems should be available in case access to electronic medical records is lost in a disaster, and that community-support networks for elderly or socially isolated individuals in a disaster could be increased. In addition to these smaller-scale interventions, attention to broader systems of inequality, such as severe economic stratification, economic recession, and the colonial relationship of Puerto Rico to the United States should also be integrated into disaster policy discussions.

It is also important to recognize how important it is for local community members establish disaster recovery and policy recommendations. The study investigators advocate the promotion and involvement of local Puerto Rican community members in the decision-making process, as opposed to the forceful imposition of external policies and changes. Many Puerto Ricans are already involved in grassroots efforts to create positive changes and developments within their communities. This sentiment was best captured by a community leader who expressed his strong belief in the potential of community groups to rebuild a stronger Puerto Rico:

“We need to make our future by ourselves. Our government is broke, we have PROMESA [debt repayment control and oversight] above us, we have hurricanes. It is hurricane season again. But if we really love Puerto Rico, we need to make it ourselves. And it is going to happen. It’s going to happen—believe me.”

Acknowledgements. Many thanks to the kind, generous, and courageous Puerto Rican healthcare workers who shared their accounts of the hurricane and its aftermath. It was an honor to hear these stories. Thank you also to the Natural Hazards Center for support and funding, and feedback with various iterations of this research plan and proposal.

References