Cuban Medical Literature
The Cuban Health System’s Response to the Effects of Hurricane Michelle

Julio Teja, MD 1

INTRODUCTION

Hurricane Michelle was the first great intensity hurricane (category 4) to hit our country in the 21 st Century. As a result, the Cuban Health System, as part of the System of Civil Defense Measures, was called upon to act in the face of the emergency. Curiously, the last hurricane of similar force to hit Cuba in the 20 th Century occurred in the same part of the country in 1952. The span of time between both events - 49 years - means two generations never experienced a hurricane of such force, only weaker tropical systems. Confronting Hurricane Michelle was a challenge to the country, and to our health system in particular.

Hurricane Michelle developed from Tropical Depression No. 15 during the 2001 cyclone season. It formed from a tropical wave in the western Caribbean Sea on October 29, 2001. At 6pm on November 4, Michelle made landfall at the Bay of Pigs, between Playa Larga and Playa Girón, Matanzas Province, as a category 4 hurricane, with sustained winds of about 136 mph (220 km/h), and stronger gusts of up to 149 mph (240 km/h), moving northward at about 9 mph (15 km/h). Later, it gradually weakened to a category 1 hurricane (maximum sustained winds of 93 mph or 150 km/h), moving out to sea at 1am on November 5, passing north of Sagua la Grande, Villa Clara Province.

Michelle was an extensive hurricane, with a diameter of 310 miles (500 km). The influence of the cyclonic circulation of its winds ranged from the eastern part of Pinar del Río to Ciego de Ávila Province, including the Isle of Youth and its adjacent keys.

1. Preparing to Respond to Hurricane Michelle

As established by National Defense Law 75 and Legal Decree 170 of May 1997, the Ministry of Public Health is accountable to the Cuban government for medically ensuring emergencies and disasters. This is done through governmental structures which are integrated within the High Command of the National Civil Defense.

Emergency and disaster plans are increasingly important as they have become working tools which define and formalize actions to be taken in these special circumstances.

Preventive, realistic planning is a must, especially in poor countries with few resources to face, prevent and mitigate nature’s severe events. These plans are working tools that make it possible to coordinate risk-reducing actions between every institution, local government and the entire population, without improvisation; this is the efficient use of human and technological resources to reduce damages. Measures to this end include timely advice to the population by all possible means and planned, preventive evacuation of high-risk populations.

Serious, fatal consequences were prevented by the implementation of prevention, mitigation and preparation measures that were included in the hurricane plans, especially timely warnings and planned, preventive evacuation of the population.

These plans stipulate that analysis and projections should be made in every municipality in the first three months of each year. Before the start of the hurricane season, each municipality undergoes an assessment and evaluation process using historical antecedents, threat maps, and architectural studies, that determine which zones are the most vulnerable and which houses and public buildings are in such structural condition that may cause them to be damaged. It is then possible to know beforehand how many people should be evacuated (children and adults), and the necessary means to ensure evacuation. Furthermore, this makes it possible for the commission on evacuation centers to approve shelters beforehand, determine their capacity, hygienic conditions, water supply, liquid and solid waste disposal systems, and assure medical care.

Our health system participates in the METEOR Exercises [emergency situation simulations] that are planned every year for the entire country by the High Command of the National Civil Defense for the whole country before the start of the hurricane season.

It is of critical importance that health personnel be trained so that everyone knows what role they are to play within the plan, the health education measures to be taken and the population’s norms of behavior to implement in case of an emergency.

The family doctor and nurse concept has made it possible to permanently allocate a doctor’s office in every community (for more on the doctor and nurse team, see MEDICC Review's November issue, 20 Years of Family Medicine). This has been a positive experience in coping with the effects of a disaster. This structure makes it possible to have qualified medical personnel right in the center of destruction or its surroundings, where they become an active factor in the population’s health education and the preparation of the “first-aid and basic-care hygiene teams.” We all know that simple hygiene and basic health education can be much more efficient than late intervention by many experts.

Cuba´s Integrated System for Emergencies is implemented in primary care by the Main Emergency Polyclinic, which coordinates a network of family doctors’ offices in close connection with the Hospital Emergency Subsystem. In addition, medical and nursing staff participates in ongoing education and courses in vital trauma support at all levels.

Another resource is the Health Analysis and Tendency Unit (HATU). This is a computerized system of epidemiological surveillance which is interconnected with all levels of the national health system allowing it to take action in controlling and implementing corrective measures when faced with any natural or induced phenomena that could affect the population’s health.

These disaster plans are managed by government leaders in every territory and by special catastrophe management posts, which are organized in “operation groups” prior to the announcement of the informative phase of a disaster. These unified and coordinated posts are the highest management bodies in each territory, in charge of the protection measures to adopt. They are equipped with means of communication and with previously trained management and coordination personnel. They are the governmental working bodies which direct and conduct the implementation of measures to protect the population in case of disaster . For more, see Spotlight: Hurricanes in Havana: A Tale of One Province .

2. Establishing Phases

When Michelle formed as a tropical depression on October 30, a number of actions had already begun to be implemented. The informative phase was established for the provinces of Pinar del Río, Havana, Havana City, Matanzas, and the Isle of Youth, where protection measures were enacted as planned. The informative phase was introduced 97 hours in advance for the western provinces of the country

According to current legislation, particularly Legal Decree 170 of the Civil Defense System of Measures, four phases are established to protect the populations in case of danger. The following parameters are established to adopt these phases in case of hurricanes:

• According to the position of the hurricane in relation to our territory - The Informative Phase is established 72 hours before the country is affected; the Hurricane Alert Phase is implemented 48 hours before; the Hurricane Alarm Phase is established 24 hours before; while the Recovery Phase is put into practice as soon as the hurricane is no longer dangerous to the country.

• The characteristics of the cyclonic body - wind speed, influence, and associated rainfall.

• The rain period and its behavior, as well as the volume of cumulative water in dams.

• The situation of schools in the countryside and non-permanent school camps in the countryside, as well as other population at risk and economic objectives.

These phases are considered part of the Medical Securing Plan for hurricanes and intense rainfall.

Based on the abovementioned information and on the tropical cyclone reports issued by the Forecast Center of the Meteorology Institute, the following hurricane phases were established in the country from the early moments of direct hurricane hazard:

Informative Phase : Introduced 97 hours before its estimated landfall for the western part of the country, and 79 hours in advance for the rest of the threatened provinces.

Hurricane Alert Phase : Established 79 hours in advance for the western part of the country, and 55 hours before its estimated landfall in the central territory.

Hurricane Alarm Phase : This phase was established 37 hours in advance for the western and central parts of the country, as well as for Ciego de Ávila Province, where it was initiated 25 hours in advance.

Recovery Phase : Established for all the affected territories when the hurricane was no longer dangerous for the country.

Hurricane Fast Facts: Mighty Michelle, November 3-5, 2001 Category 4 Hurricane Highest sustained winds: 136 miles per hour ( 220 km/h) Highest wind gusts: 149 miles per hour ( 240 km/h) Most rain that fell in a 24-hour period: 9.22 inches ( 234.3 mm) in Arroyo Arenas, Ciudad de la Habana Province Greatest wave height: 13.12 to 16.4 feet (4 to 5 meters) along the south coast of Isla de la Juventud and Miramar and Vedado in Ciudad de la Habana Farthest ocean penetrated inland: .62 miles ( 1 kilometer) in Cárdenas, Matanzas Province Diameter of the hurricane eye: 24.8 miles ( 40 kilometers) Reach of hurricane winds (in diameter): 310 miles ( 500 kilometers) Percentage of Cuban territory affected: 52%s (home to 53% of the population or 5.8 million people) Deaths in Cuba: 5 Deaths in Caribbean & Central America: 17 Number of homes completely destroyed: 12,579 Number of homes damaged: 153,936 Estimated amount of sugar destroyed: 400,000 tons Estimated amount of citrus destroyed: 398,000 tons Estimated agricultural losses: US$577 million (US$317 million in damages plus US$260 million in lost production) Total cost of recovery effort: US$785 million

3. Major Measures Taken:

a) 1295 catastrophe management posts were activated, including:

12 Provincial posts

151 Municipal posts

1,132 Posts in defense zones

b) 102,468 people were mobilized, including those in the health sector, which represented 41% of the number estimated.

c) 6,095 means of transportation were used with different purposes, which represented 82% of what had been planned for. This number included more than 1,000 ambulances and other transport for the health sector.

d) In the Hurricane Alert Phase 219,729 students in the countryside were evacuated. 219,206 of them were evacuated to their own homes, while 522 were lodged in shelters. Primary medical care was ensured for all of them with family doctors.

e) A total number of 564,031 people were evacuated, 166,339 of which were lodged in shelters. The rest of the evacuated people were protected in houses of relatives and neighbors. This has been one of the highest figures of evacuated people in the history of our country, with no accidents or human losses during the evacuation process. [The number of evacuees during Hurricane Ivan in September, 2004 was more than triple that - 1,898,396 people - also without accidents or injuries. Eds. note].

f) 777,668 animals were evacuated to safer zones, including 320,364 cattle, 288,590 of other types of livestock, and 376,198 fowl.

g) 1,028 previously planned shelters were activated nationwide. Medical posts were established in all of them in compliance with the health sector plans. All Family Doctor’s offices remained active to care for the population that was evacuated in their relatives’ houses and in zones affected by the hurricane.

h) Preventive medical care and epidemiological surveillance were provided to the affected population. Sanitary control measures were taken with regards to water supply quality, disposal of solid and liquid waste, food hygiene, and control over insects and rodents.

i) Other measures adopted included:

Tree pruning was accelerated before the hurricane in those cases in which trees were hazardous to the population, buildings or electricity. Other measures included garbage collection, removal of billboards, signs and other objects that could be swept away by the wind.

Specialized forces were activated for rescue tasks and urgent damage trouble-shooting.

Administrative government bodies responsible for the major assurance measures activated their emergency plans to guarantee protection of the population and the economy.

Epidemiological surveillance measures were increased.

The population was instructed on what measures to implement in each phase. A crucial role was played by the family doctors as they informed the population on hygienic and sanitary measures, norms of behavior to follow in these circumstances, and provided psychological support after the hurricane.

As conceived by the Ministry of Basic Industry, power circuits were switched off in coordination with the National Electricity Board in those places where wind speed exceeded 43 mph (70 km/h), in order to prevent short-circuits, transformer burns and accidents affecting human lives.

A few hours before possible landfall of the hurricane, the Minister of Public Health called a coordination meeting to finalize details on the protection measures. The seven following actions were established within the number of health-related activities to carry out:

• Prevent damages to people’s health by means of prevention.
• Guarantee an adequate number of hospital and out-of-hospital beds for medical care. Between 20% and 30 % of hospital beds were made available and new admissions were limited to emergency cases. Consultations were cancelled.
• Give special attention to usually isolated zones with supporting medical brigades.
• Prevent damages to health units.
• Activate the integrated medical emergency service for disasters.
• Guarantee medical and medical-hygienic-sanitary care to the evacuated population.
• Prevent epidemics in the affected population (epidemiological surveillance).

4. Major Damages

In general, it was necessary to adopt protection measures against Hurricane Michelle from Pinar del Río to Camagüey, including the Isle of Youth Special Municipality, affecting 52% of the whole Cuban territory where 53% of the population lives (about 5 million inhabitants).

During Hurricane Michelle, five deaths were reported, and 10 other people were slightly injured.

A large number of houses (131,000) were affected, as well as hundreds of schools and other social institutions and economic installations that included sugar mills and agricultural facilities. Serious damage was also caused to electrical power lines, communications, water and gas supply, and the road system.

In agriculture, most of the damages were to citrus, banana, aviculture, and various crops. Great losses were reported in different species of cattle and fowl intended for the population.

As regards the health sector, the major losses and damages reported were:

• 839 units of the National Health System were affected. Of these, 609 of them were slightly damaged (72.5%); 214 were partially damaged (25.5%), and 16 were completely destroyed (2%). It was necessary to implement alternative solutions given the existing conditions and the need to continue providing medical care.
• Most damages were found in roofs, dropped ceilings, doors and windows, transformers and electrical networks.

Damage Recovery

By January 14, 2002, approximately two months after Hurricane Michelle passed through Cuba, 400 health care units had been recovered, representing 48% of all those affected. It must be emphasized that regardless of how damaged they were, all of our units continued to offer medical care to the population as their good condition was being reestablished. Thanks to very close coordination, limitations on care were solved by other institutions in the same province, or in other provinces if required.

CONCLUSIONS

Considering the hurricane’s magnitude and its impact on the country’s infrastructure, it should be pointed out that the prevention, preparation and response measures that were put into practice by the Civil Defense System of Measures – including those pertaining to the Health System – were a key factor in reducing the hurricane’s impact on our people’s lives and health. They guaranteed the vitality of medical care in accordance with what was needed, maintained the system of epidemiological surveillance, reinforced sanitary norms and the understanding of them by the people, and ensured quick recovery from the damages suffered by the health sector, thus contributing to maintaining and recovering the levels of the quality of life of our population.

THE AUTHOR

1- Former Minister of Public Health; Specialist at CLAMED; teja@infomed.sld.cu.

This article was reprinted from Gerencia de Desastres en Cuba , published in 2003 by the Caribbean Disaster Information Network (CARDIN), the European Commision Humanitarian Aid Office (ECHO), and the Latin American Center for Disaster Medicine (CLAMED), pp. 160-164.