Hurricane Maria was one of the worst natural disasters that the United States—and in particular Puerto Rico—has seen. In September 2017, the Category 5 hurricane cost the lives of nearly 3,000 people. The impacts can still be felt on the island.
Absent from much of the media coverage of Maria, however, was its impact on people who use drugs—particularly those living in rural areas of Puerto Rico, further away from the social supports that cities represent.
New research, however, details how this population was harmed in the aftermath of the disaster. More broadly, the study highlights the need for better emergency supports for people who use drugs—particularly as climate change increases rates of floods, wildfires and other extreme weather.
Roberto Abadie, an assistant professor in the University of Nebraska-Lincoln’s department of anthropology, is one of the authors of the paper, which was published in the Harm Reduction Journal. Dr. Abadie and his team were originally planning to study the general impact of fentanyl on rural people who use drugs on the island. As such, they initially made contact with 110 people from this population.
But the onset of Hurricane Maria, and the opportunity to assess its impacts, shifted the focus of their inquiries. The team ended up collecting interviews from a total of 66 people both before and after the disaster, with interviews concluding in 2019.
Of those who continued to inject opioids in the wake of Maria, more participants reported reusing needles.
“You know, we had some trouble publishing this article, because some of the editors felt that our sample size was variable, and also small,” Abadie told Filter. The original cohort decreased because in the wake of the hurricane, some people moved from rural areas to Puerto Rico’s capital, San Juan, or to the continental United States. Other members fatally overdosed, Abadie said.
The paper found that after Hurricane Maria, participants injected less frequently overall. The percentage of people who said they injected only once per month or less rose from 3 percent pre-Maria to 22.7 percent afterwards.
According to Abadie, some people just stopped injecting opioids, which largely contained fentanyl. These respondents didn’t tend to switch to other ways of ingesting opioids, like smoking or swallowing, he said, but instead began using different substances, such as illicit benzodiazepines, crack cocaine, alcohol or synthetic cannabinoids.
But of those who continued to inject opioids in the wake of Maria, more participants reported reusing needles. The paper notes that 76.9 percent said they predominantly or exclusively used new needles pre-Maria. Post-Maria, that fell to 55.4 percent.
The number of non-fatal overdoses among participants also more than doubled after the hurricane. Pre-Maria, 10.6 percent said they had experienced an overdose in the year in which they were interviewed or the calendar year prior. This increased to 24.4 percent after the disaster.
The study does not claim to prove the extent to which these increased risks were caused directly or indirectly by the hurricane, or by factors such as a changing drug supply. But it notes that “the results nonetheless characterize an altered risk environment for [people who inject drugs] in Puerto Rico after Hurricane Maria, relative to before.”
The paper notes, too, that across Puerto Rico, clinics offering medications like methadone closed down, and syringe provision efforts were disrupted—Puerto Rico does have a syringe service program that focuses on its rural populations. Hurricane Maria and its aftermath also harmed people’s mental and economic wellbeing, beyond causing physical damage to the island and its residents.
But rural residents who use drugs were particularly impacted. Some of this is because health and harm reduction services were already scarce in rural areas, but there were other intersecting factors. “[Colonialism], rurality, poverty, you add everything to the mix,” Abadie said.
Tanagra Melgarejo Pulido, national learning and engagement strategist with the National Harm Reduction Coalition (NHRC), spoke of the harm reduction groups that did work to provide services in the wake of Hurricane Maria.
NHRC and other groups are discussing how to provide care during natural disasters, and in a future when “emergencies are going to get much more intense.”
“I think that local harm reduction programs were key in not only supporting people who use drugs, but also in supporting [other] members of the community that were impacted and affected by the hurricane,” she told Filter.
However, she said that NHRC and other groups in the space are discussing how to provide care during natural disasters, and in a future when “emergencies are going to get much more intense.”
Some of this comes down to thinking about ways to be prepared in advance and what tools community and local harm reduction groups need to have on hand. But she added that disaster relief agencies regularly forget about people who use drugs when providing aid, so part of it will likely involve having conversations with agencies such as FEMA.
Abadie said that there needs to be more research into how to meet the needs of people who use drugs, especially in rural areas and among marginalized groups, during events like hurricanes, wildfires and floods.
Some options to improve care during these periods, he suggested, could include mobile methadone clinics, easing access to methadone or similar medications, creating stores of these drugs, and providing better funding for harm reduction efforts in rural areas more broadly.
“We need to think more carefully about harm reduction in natural disasters,” he said.
Photograph of an area of northern Puerto Rico after Hurricane Maria by US Department of Agriculture via Flickr/Public Domain