The Puerto Rico Department of Health (PRDOH) placed the lives of Puerto Ricans “at risk” by failing to effectively implement a preparedness and response protocol during Hurricane María, a federal government audit concludes.

The investigation by the U.S. Department of Health and Human Services’ Office of the Inspector General (HHS-OIG), published in July 2021, establishes that the PRDOH did not effectively implement a collaborative agreement to handle emergencies.

A chain of mistakes and omissions by the PRDOH led to it being the only agency of any state or territory to be audited by the federal government. The PRDOH did not carry out specific preparedness and response initiatives for the most vulnerable people, such as children, the elderly, the sick, the disabled, the geographically isolated, and those with a language or cultural barrier, as required by the collaborative agreement.

The PRDOH also failed to obtain public comments on its Emergency Operational Plan, which was a requirement of the agreement. The Puerto Rican agency did the opposite: it claimed it was confidential. Because it was hiding that document, the Center for Investigative Journalism (CPI, in Spanish) had to go to court to gain access to it.

“The lack of input from stakeholders may have limited PRDOH’s hurricane preparedness, response, and recovery efforts,” according to the audit report.

Added to the lack of transparency was the agency’s inability to maintain a communications system that would enable its volunteer corps to be activated in the event of an emergency. Before Hurricane María, the PRDOH relied exclusively on telephones to contact them, with no alternate method. When it was most needed to activate them, during the worst natural catastrophe that the island has faced in 100 years and that had toppled the telecommunications infrastructure, the Department of Health could only find 15 people on the list, who at that time had already left Puerto Rico because of the emergency. That’s a mere 2% of the 700 that were in the volunteer database.

The missteps came one after the other. The HHS-OIG notes that the PRDOH was not prepared to deal with surges of death and handle the bodies (which ultimately turned into a crisis in hospital morgues and the Institute of Forensic Sciences). The PRDOH also faced problems when procuring equipment because it did not apply procedures for expediting the procurement of equipment with the collaboration of the General Services Administration. The PRDOH followed ordinary purchasing mechanisms, resulting in not having the tools it needed in time to face the emergency.

“We felt that if they improved in these areas, it would help with not putting the residents at risk,” Stephanie Pizzillo, Assistant Regional Inspector General at HHS-OIG, told the CPI.

That federal agency not only reviewed compliance with the cooperative agreement but also the PRDOH Emergency Operations Plan Plan as well as the attempts at corrective actions after the incidents to determine how effective the preparation and response to Hurricane María had been.

“Puerto Rico submitted the same plan annually. It didn’t look like it was updated,” Pizzillo said. 

The cooperative agreement was signed in 2012, under the first tenure of former Health Secretary Lorenzo González, who was appointed by the New Progressive Party (PNP, in Spanish) administration. The agreement was to be in effect for five years, which included 2017, the year when Hurricanes Irma and María struck.

The audit covers the period of fiscal years 2017 and 2018, when the PRDOH was directed by Rafael Rodríguez Mercado, who was appointed by former governor Ricardo Rosselló. During these years, PRDOH received $19.1 million to implement the cooperative agreement. Rodríguez Mercado did not answer questions from the CPI regarding the audit findings and the status of the cooperative agreement when he began directing the agency.

On March 3, 2021, current PRDOH Secretary Carlos Mellado sent a letter to the federal agency when it was preparing the report. He alleged that the conclusions that the HHS-OIG was considering did not reflect the “reality” of what had happened at the local health agency. Mellado, who was appointed as the agency’s secretary in December 2020, rejected the conclusion that the PRDOH had not implemented the plans effectively under the Rodríguez Mercado administration. 

Mellado claimed that the impact of the hurricanes had been unprecedented, early on during a new government administration. 

“This implies that all State Agency Leads and Directors were newly appointed to their roles and did not have the opportunity to receive Emergency Preparedness and Response training before this emergency, as specified within the PRDOH’s Emergency Operations Plan (EOP),” according to Mellado’s letter. 

When the hurricane hit the island four years ago, the highest decision-making authority in all emergency response initiatives had been delegated by Rosselló to the Department of Public Safety, a new umbrella agency for seven government agencies, then headed by Héctor Pesquera.

“This action dislocated decisional and communication processes since there was a lack of knowledge and understanding of requirements for the implementation of response activities […],” Mellado said. 

Mellado’s observation coincides with the constant complaints by emergency management experts and the opposition to the PNP, who warned about the Department of Public Safety’s alleged excessive bureaucracy after its creation in 2017. A proposal to eliminate the agency is alive at the Legislature to restore autonomy to the entities it covers: the Police, the Fire Department, Medical Emergencies, Emergency and Disaster Management, the 911, and the Bureau of Special Investigations. The Institute of Forensic Sciences was under the  Department of Public Safety during Hurricane María, but it regained its independence in 2020.

The HHS-OIG agreed that the impact of the 2017 hurricanes was unprecedented. “However, we maintain that the start of a new government administration should not affect emergency preparedness.”  

After evaluating Mellado’s comments, the Inspector General maintained the findings and reminded him that the PRDOH is responsible for the implementation of the agreement. The agency must comply with it in coordination with the Office of the Assistant Secretary for Preparedness and Response (ASPR), the HHS division that grants funding and determines what corrective actions to take.

The PRDOH did not respond to questions sent by the CPI, including explaining what steps the current administration has taken to correct the deficiencies.

“There’s a price to pay for politicizing our agencies,” said Ralph Rivera, professor at the University of Puerto Rico’s School of Medical Sciences, when analyzing the report. As chief researcher of the Center for Emergency Preparedness, he was in charge in 2009 of a study to document the needs of vulnerable populations, and in 2012 he prepared the PRDOH’s emergency plan, the last one done with the participation of the UPR, Rivera indicated.

“This is the first time that I see that the government of Puerto Rico acknowledges that nine months after a new administration it was incapable of meeting its commitments. If we had to be prepared for something, it was for a hurricane. There was money allocated to prepare. The politicization of the Department of Health, where there isn’t adequate transition, where people who have the expertise are removed or delegated to different roles, leaves us lacking the required level of expertise,” Rivera added.

No dedicated plan for the at-risk population

The collaborative agreement called for a drill in 2017 that would include specific protocols for the population at risk, with an evaluation of its strengths, weaknesses, and corrective actions. The PRDOH needed to identify shelters that could meet those people’s special needs and coordinate with health care organizations so they would provide them with specialized services. The agency had to make sure there were emergency resources such as oxygen tanks.

According to the HHS-OIG, none of this happened as the agreement required. The PRDOH did arrange for disadvantaged communities to be assisted in shelters, but on a limited basis, and not as part of a special protocol.

“As a result, PRDOH was not prepared to effectively locate and reach at-risk populations throughout the Commonwealth, thereby placing the health and safety of these populations at risk,” the report states. 

Mellado excused the Department of Health stating that, in Puerto Rico, the departments of Housing, Education and the municipalities are responsible for managing the shelters.

The HHS-OIG recalled that, as part of the agreement, it is the PRDOH that must lead the processes of identifying areas and resources for people with special needs.

Forensic Science plan is obsolete

Before Hurricane Maria, the Institute of Forensic Sciences (ICF, in Spanish) had the capacity to simultaneously store up to 140 corpses, although it could fit 75 more in case of an emergency, according to the report. To receive more bodies, the ICF planned to store them in refrigerated containers and in industrial spaces, for which it would need federal help.

The HHS-OIG states that the ICF’s emergency plan was outdated, and it was not prepared to deal with surges of death.

Hurricane María caused an excess of 2,975 deaths, according to a report by George Washington University commissioned by the government of Puerto Rico, which resulted in problems of space and handling of the corpses.

The HHS-OIG confirmed that the PRDOH also lacked a protocol that doctors could follow to certify that the victims had died due to the hurricane, which may have resulted in an underestimated count of hurricane-related casualties, as journalistic investigations revealed.

The absence of a process to identify victims was one of the most significant problems that came up after the hurricane hit, as the CPI reported. Federal health authorities recommended establishing a process — as a separate protocol — to certify the causes of deaths, the report said.

Mellado told the HHS-OIG that Forensics is the agency that oversees the bodies and is responsible for certifying the deaths. But the federal agency reminded him that, as part of the collaborative agreement, the PRDOH has the responsibility to develop plans and coordinate the response from a public health standpoint.

The CPI asked Pizzillo, Regional Assistant of the HHS-OIG, why the PRDOH is responsible if the ICF is in charge of handling corpses.

“We understand this is not the primary responsibility of the Puerto Rico Department of Health, but there should be some coordination. And when they sign a proposed agreement, they do agree to those terms… they’re also taking responsibility to make sure that there are things in place,” Pizzillo said.

No communication among health sector components
The PRDOH did not clearly define the roles and responsibilities of the officials who were to coordinate the Health Care Coalitions (HCC ). They include public, private and nonprofit entities such as hospitals, drugstores, laboratories, emergency management organizations, voluntary organizations, interfaith entities and funeral homes, among others, that must work together during disasters.

The report mentions four employees (but does not disclose their names) who were named PRDOH zone coordinators and did not fulfill their responsibility to coordinate the HCC.

The PRDOH also did not establish procedures for HCC members to share information in real-time about the resources needed to respond to the emergency or to get details about other organizations. Most hospitals, for example, had access to a database but only to enter information, while laboratories and dialysis centers had no access at all.

PRDOH officials said this is a data entry tool for hospitals, which did not allow information to be exchanged because some members of the HCC did not want to share the data with their competitors.

“Because all HCC members could not access the database, and there were no alternative methods for sharing information about resources and needs to address the emergency, HCC members were unable to obtain specific, timely, relevant information on resources or needs in the aftermath of Hurricane Maria, thereby placing the health and safety of Puerto Rico residents at risk,” the report states. 

The PRDOH concurred with the HHS-OIG’s findings about its shortcomings in managing the health coalitions.

The reason for the investigation

Under a congressional mandate, the HHS-OIG has conducted four audits starting in 2018, of which three were of federal entities under the HHS umbrella: the Administration for Children and Families, the Health Resources and Services Administration, as well as the Centers for Disease Control and Prevention. The audit found that all three had controls and strategies in place to mitigate preparedness and response risk.

Of the four audited entities, the PRDOH was the only one found to be noncompliant.

The CPI asked why the Department of Health was the only agency from a state or territory to be investigated, considering that other places such as Texas and Florida were hit by hurricanes in 2017.

“We have limited resources to conduct audits. Risk assessments are performed to determine the areas of focus,” according to the HHS-OIG.