Hurricane Harvey

Water, rather than wind, was the defining hazard for Harvey.^{Reference Shultz and Galea1,Reference Blake and Zelinsky7} Harvey pummeled the Houston area with 33 trillion gallons of rain over 5 days, producing widespread urban flooding. Many residents, including some with T1D, were trapped as floodwaters rose precipitously.

Persons with T1D faced compounding threats: minimal warning and inability to evacuate due to Harvey’s rapid intensification; exposure to deluging rains and life-threatening floods; displacement from inundated neighborhoods; loss of electrical power and communications; and shutdown of healthcare facilities.^{Reference Shultz and Galea1,Reference Shultz and Galea2,Reference Blake and Zelinsky7} Individuals with T1D were cut off from sources of insulin, diabetes care supplies, and access to diabetes specialists and clinics.

Co-author Stephen Ponder described the time-urgent activities that successfully maintained the flow of diabetes care and supplies in the Houston area during Harvey. An “organic” grassroots response evolved, with diabetes professionals self-enlisting to safeguard persons living with T1D. Dubbed “T1 Team Texas,” these volunteer professionals developed a functional network to funnel diabetes supplies to pockets of persons in need. The team procured sizeable quantities of insulins (from sources such as Insulin for Life, Gainesville, FL) and diabetes care supplies. They engineered a multi-level distribution system consisting of diabetes supply stockpiles feeding smaller nodes that served defined geographic areas. They arranged for volunteer personnel and transport equipment to bring critical diabetes supplies to flooded neighborhoods. In some instances, this involved wading through waist-deep water to deliver insulins to the doorstep of individuals with T1D.

Benefitting from Dr. Ponder’s robust social media presence across Texas, persons living with T1D who required urgent re-supply of insulins could be identified. Social media provided the “nervous system” for micro-targeting supply requests to nearby stockpiles and volunteers who could effectuate delivery.

The success of this endeavor is credited to clinician “champions” who emerged to assume leadership responsibility and achieve continuity of operations. These self-identified professionals were able to seek and stockpile shipments of insulins, create caches of diabetes supplies, coordinate lines of distribution, and respond to time-sensitive requests made through social media. Improvisation was also a driving force that propelled this expanding cascade of team activities.

Hurricane Irma

Co-author Della Matheson provided her observations on the Miami experience for persons living with T1D. Hurricane Irma was an extremely strong Atlantic storm that impacted 14 Caribbean small island states.^{Reference Shultz, Kossin and Shepherd4,Reference Cangialosi, Latto and Berg8,Reference Zakrison, Valdés and Shultz9} For days, Florida residents witnessed Irma’s catastrophic march across the Caribbean. When the forecast track had Irma moving directly over Miami and northward along Florida’s populous east coast, millions of Floridians opted to evacuate. Outbound flights sold out days before landfall. For South Floridians, evacuation meant navigating Florida’s 400-mile-long peninsula to escape from harm. Massive volumes of vehicles clogged the northbound routes. Fuel was in short supply, traffic was in slow-motion gridlock, and hotel rooms were sold out throughout Florida.

For persons living with T1D, the preimpact phase was extremely distressing. Sheltering in place meant the likely loss of electrical power, air conditioning, and refrigeration; subjecting them to Florida heat and humidity with decreased access to diabetes health services and supplies. The alternate choice was to evacuate. Fears of running out of insulin or “getting caught on the road” were prominent stressors reported by persons with T1D. Evacuation could only commence after visiting the pharmacy to purchase extra insulin, acquiring weeks of diabetes supplies, and packing coolers to keep the insulin chilled. Fortunately, in Florida, once the Governor issues an emergency declaration, local pharmacies are allowed to dispense an extra month of insulin and diabetes medications in advance of a storm.

Ultimately, Irma moved farther west before turning north. The southeast coastline was relatively spared as Irma’s strongest winds and waves battered the entire vertical length of the Florida’s Gulf coast. Fifteen million Floridians lost electrical power. In Miami-Dade County, the direct impact phase of Hurricane Irma in Miami lasted 1 day. Damage was moderate. Although many communities lost electrical power and Internet connection for days to weeks, roadways remained open and healthcare system closures were brief. Persons with T1D were not separated from care. Along Florida’s west coast, moderate damage extended diffusely across much of the state. Irma diminished in strength as the storm moved northward, power was rapidly restored, and access to health systems and pharmacies was minimally disrupted.

One observation made by Ms. Matheson calls for action. Care for persons with T1D in Miami was a matter of economics. Persons of lower socioeconomic status were less able to evacuate because of limited means, or to evacuate early because of job demands. They had minimal funds to allocate for purchasing an extra month of insulin or stocking diabetes supplies. Disadvantaged individuals were more likely to have sheltered in place, experienced power outages, run low on diabetes essentials, or developed diabetes-related complications.

Hurricane Maria

Hurricane Maria was purely an island storm, striking 16 small island states in succession. Hurricane Maria cut a diagonal swath across Puerto Rico, destroying the centralized power grid and thrusting Puerto Rico into sweltering darkness.^{Reference Shultz, Kossin and Shepherd4,Reference Pasch, Penny and Berg10,Reference Ferré, Negrón and Shultz11} Power outages lasted months in many municipalities. The healthcare system was hobbled. Water systems became contaminated.^{Reference Shultz, Kossin and Shepherd4}

Co-author Carlos A. Leyva Jordán described the outreach efforts necessary to bring supplies and healthcare services to persons with T1D throughout Puerto Rico, where both incidence and prevalence of T1D is high.

In contrast to the support for persons with T1D in Texas and Florida that relied on social media communications, in Puerto Rico, Internet connectivity was obliterated and 95% of cellphone towers were down. Attempts to contact patients with T1D by means of landline or cellphone were severely hampered due to the combination of protracted power outages, inoperable cellular service, and inability to charge or replace batteries for communications devices. In fact, the sole communications medium that remained intact was AM radio. It took Dr. Leyva Jordán 4 days after Maria’s landfall to be able to reach Dr. Ponder, Ms. Matheson, and Carol Atkinson (Insulin for Life) by means of email to arrange for insulin shipments.

Some pediatric patients with T1D departed Puerto Rico for mainland United States as outbound flights became available. Otherwise, for weeks following impact, patient encounters were limited to those patients who made their way to the clinics. Meanwhile, due to power outages, physicians could not access their patients’ electronic medical records. Pharmacies could not view prescription databases or receive doctors’ refill orders electronically, causing delays in dispensing insulins and diabetes medications. Initially, attempts were made to work through the department of health in Puerto Rico to facilitate the distribution of insulin products; however, the logistics rapidly became mired in bureaucracy. Pragmatically, it was easier to distribute insulin through the private sector.

Most persons with T1D could not refrigerate their insulins. This led some patients to mistakenly discard insulin products based on the misguided belief that the products could not be stored at room temperature. Dr. Leyva Jordán emphasized that educational efforts are needed to teach patients that unopened insulins stored below 86°F retain effectiveness for months, and opened insulins can last up to 28 days at this temperature.

Air conditioning units and electric fans were inoperable, so people with T1D could not easily regulate their exposure to Caribbean heat, making it more difficult to control blood glucose. It was generally not possible to refrigerate insulin. Transport of insulins and diabetes supplies to persons throughout Puerto Rico, especially in the interior municipalities, was severely delayed due to mudslide-blocked highways, damaged vehicles, fuel shortages, and closed pharmacies and medical centers.^{Reference Shultz, Kossin and Shepherd4,Reference Ferré, Negrón and Shultz11} Diabetes professionals made repeated attempts to check on the status and improvise approaches for getting diabetes supplies to isolated communities.

Mental health was a major issue for those with T1D. Because evacuation was not an option for an island-based population, many Puerto Ricans were directly exposed to Maria’s full fury; high rates of posttraumatic stress disorder (PTSD) have been documented.^{Reference Ferré, Negrón and Shultz11–Reference Espinel, Galea and Kossin13} Furthermore, being subjected to unrelenting heat and humidity for months and enduring poststorm adversities while striving to maintain diabetes care regimens exacts a psychological toll on people with T1D and their family members. Dr. Leyva Jordán observed pervasive stress and symptoms of depression among his caseload of pediatric T1D patients and their family members and caregivers.