The Future Health of Puerto Rico after Hurricane Maria

Darieliz Michelle Lopez, her 20-month-old son and three-year-old daughter sit on a sofa where her apartment stood in San Isidro on Sept. 28. (Andres Kudacki for TIME) 


In 2013, Orlando Sotomayor, a professor of economics at the University of Puerto Rico-Mayagüez, looked into whether two hurricanes in 1928 and 1932 impacted the long-term health of the people of the island. He specifically explored whether people exposed to the hurricanes prenatally had higher rates of various chronic diseases and lower education levels decades later.

He framed this within what used to be referred to as the fetal origins of disease hypothesis, but is now usually called the DOHaD (developmental origins of health and disease), acknowledging the importance of development beyond the fetal period. In a nutshell, the DOHaD is based on decades of evidence that various biological insults (malnutrition, maternal psychological stress, pollution) in the prenatal and early postnatal stages of life may predispose individuals to chronic diseases later in life. This has been linked to type 2 diabetes, coronary heart disease, and hypertension (Barker 1994), schizophrenia (Wahlbeck et al 2001), osteoporosis (Cooper et al 2009), and possibly cancer (Walker and Ho, 2012).

In one of the best-known examples, women who were pregnant during the Dutch “hunger winter” in World War 2 had offspring who had a higher risk of various conditions by the time they reached middle age, including a doubled rate of coronary heart disease, obesity, and diabetes in adulthood (Rooseboom et al 2011). They also had an increased chance of having schizophrenia and depression, and did worse on cognitive tasks. While famine conditions are not necessary to have such impacts (poverty and deprivation operate in a dose-like fashion), the well-defined period of the “hunger winter” provided a way to compare exposed and unexposed persons. 


The 1928 and 1932 Hurricanes

Professor Sotomayor viewed the decades-old hurricanes in Puerto Rico as akin to something like the Nazi-imposed famine in the Netherlands. There are differences, obviously. Disasters resulting from intentional, anthropogenic (human-generated) disasters like war usually end up leading to protracted humanitarian crises (Schultz et al 2014). While natural disasters are often devastating, they are usually short-lived and can be ameliorated by humanitarian aid, whereas unsafe conditions during war often makes such assistance logistically difficult. Of course, aid following natural disasters depends on the scale of destruction, a country’s pre-disaster wealth and access to resources, and the political willingness of neighboring countries to assist.

Hurricane San Felipe (1928) and hurricane San Ciprian (1932) both had devastating effects on the agrarian economy of Puerto Rico, with damages estimated to be about one-third and 20% of national income, respectively (Sotomayor, 2013: 282-3). Coffee, citrus, and sugar cane crops were particularly affected. Using data from the CDC Behavioral Risk Factor Surveillance System surveys, Sotomayor looked at people born between 1920 and 1940, and defined those individuals born in the years immediately following the hurricanes (1929 and 1933) as having been exposed to difficult early life conditions. Unfortunately, month of birth was not available in the dataset, so year of birth had to suffice.

Plantain trees flattened by Hurricane Maria in Yabucoa, P.R. In a matter of hours, the storm destroyed about 80 percent of the crop value in Puerto Rico, the territory’s agriculture secretary said. Credit Victor J. Blue for The New York Times


In all, the sample comprised 11,990 individuals, with 1,197 defined as being exposed to the effects of the hurricanes in early life. Overall, he found that exposed individuals were more likely to be diagnosed with hypertension, high cholesterol, and diabetes, as well as be more likely to have no formal schooling. This latter outcome variable was interpreted as possibly being a “cognition shock,” suggesting that exposed individuals may have had some decline in mental faculties resulting from poor early neurological development.

Incidence (and 95% confidence intervals) of chronic diseases and lack of schooling in Puerto Rico by year of birth. People born in 1929 and 1933 were viewed as being exposed to the effects of a hurricane in early life (Sotomayor 2013).



After Hurricane Maria

We can speculate whether something similar might result from hurricane Maria, which made landfall on Puerto Rico on September 20 of this year. As a Category 5 hurricane, it was among the most powerful ever recorded and its devastating effects likely won’t be resolved anytime soon. It has been estimated that more than 1,000 people died as a result of Maria, while a substantial proportion of the population still remains without electricity, months later.

Similarly to Hurricanes San Felipe and San Ciprian, Maria destroyed up to 80% of Puerto Rico’s agriculture, and rates of food insecurity have increased (rates were already high before the hurricane). Reports indicated that following the hurricane, many people on the island had to skip meals and waited in lines for hours waiting for emergency food supplies, as relief supplies were below standards that were available in other recent hurricanes that hit Texas and Florida (even though all are American citizens). According to CBS News, more than 215,000 people left Puerto Rico for Florida between October 3 and December 5, and it’s been projected that perhaps more than 470,000 people will leave in the next two years (and up to 750,000 people over the next four). Proportionally, this is a staggering loss of population on an island that had 3.4 million people in 2016.

A combination of NOAA satellite images taken at night shows Puerto Rico in July, top, and on Sept. 24, 2017, after Hurricane Maria knocked out the island’s power grid. NASA/NOAA/Handout/Reuters


All of this suggests that there is the potential that Maria could have long-term effects on health, growth, and development similar to San Felipe and San Ciprian. Early life is a particularly vulnerable period, and there are an estimated 175,000 children under the age of  to 4 years old on the island. Growth rates are fastest in this stage, and the potential for long-term effects on health should factored into Maria’s costs beyond the effects on mortality, damaged infrastructure, destroyed crops, economic losses, and displaced population. It also hints at the urgent need to summon the political will to respond rapidly and sufficiently to minimize the effects of natural disasters like this. Otherwise, the costs will have to be paid later in terms of loss of health, premature death, and possibly diminished cognitive capacity (and all of its concomitant costs to education and economic potential). As Professor Sotomayor wrote (2013: 291):

“Evidence therefore suggests that in absence of preventive measure, effects of events like Bay of Bengal cyclones, Caribbean Sea storms like hurricane Mitch, or the great Haitian earthquake may not be over for a long time.”



Barker DJP. Mothers, Babies, and Disease in Later Life. BMJ Publishing; 1994.

Caruso GD. The legacy of natural disasters: The intergenerational impact of 100 years of disasters in Latin America. Journal of Development Economics. 2017 Jul 31;127:209-33. Link

Cooper C, Harvey N, Cole Z, Hanson M, Dennison E. 2009. Developmental origins of osteoporosis: the role of maternal nutrition. Early Nutrition Programming and Health Outcomes in Later Life. 2009:31-9. Link

Shultz JM, Ceballos ÁM, Espinel Z, Oliveros SR, Fonseca MF, Florez LJ. 2014. Internal displacement in Colombia: fifteen distinguishing features. Disaster Health. 2(1):13-24. Link

Sotomayor O. Fetal and infant origins of diabetes and ill health: Evidence from Puerto Rico’s 1928 and 1932 hurricanes. Economics & Human Biology. 2013 Jul 31;11(3):281-93. Link

Wahlbeck K, Forsen T, Osmond C, Barker DJ, Eriksson JG. 2001. Association of schizophrenia with low maternal body mass index, small size at birth, and thinness during childhood. Arch Gen Psychiatry 58: 48-52. Link

Walker CL, Ho SM. Developmental reprogramming of cancer susceptibility. Nature Reviews Cancer. 2012 Jul 1;12(7):479-86. Link

Human Biology of Poverty Symposium

We just finished a symposium on “the human biology of poverty,” held at ISCTE-IUL in Lisbon, and sponsored by the The Society for the Study of Human Biology. It really was a great meeting, full of important research on the effects of various forms of deprivation on biology and health in different populations. The complete program can be found here.

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The Biology of Forced Displacement

“Seeking asylum is not illegal under international law and people have a right to be treated humanely and with dignity.”  – UNHCR

We crossed the Mekong to get to Thailand at night, so no one would see us. We had always lived in the mountains (of northern Laos), so we did not know how to swim. When we came to the river, we used anything to help us float – bamboo, bicycle tubes. But at night, it is easy to get lost. Someone in our group said: ‘Remember, if you get lost when you’re going down the river (with the current), don’t panic. Thailand is on your right.’ ”



Every refugee has a story. The one above was told to me by a Hmong man I met in French Guiana in 2001. I went to learn about the experiences of the people there and how they had adjusted to being resettled half a world away, from Southeast Asia to a French ‘overseas department’ in Amazonia. They were actually doing quite well at the time, living as independent farmers who had been given land by the government years earlier.

Hmong men in French Guiana going hunting by bike.

Hmong men in French Guiana going hunting by bike.

They also retained a good degree of cultural continuity. While most are fluent in French, the majority of the 2,000+ Hmong in the country lived in rural, semi-isolated, ethnically homogenous villages. This gave them a buffer of sorts, allowing them to acculturate on their own terms. As they often put it, they were “free to be their own boss,” free to be Hmong, and most said they were happy with life in French Guiana. This combination of traits – economically self-sufficient, culturally distinct, mostly content, living in a rural overseas department – is not the typical refugee story. In fact, because of that relative uniqueness, the French Guiana Hmong have drawn attention from media outlets such as the BBC and the NY Times.

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Civilians, Refugees, and the 2nd Indochina War in Laos

In Houa Phanh and Xieng Khouang provinces, the war (in Laos) has reached into every home and forced every individual, down to the very youngest, to make the agonizing choice of flight or death.” (Yang 1993: 104)

Those who suffered the most from the escalating conflict were populations living in the east of the country: overwhelmingly highland minorities, Lao Thoeng and particularly Lao Sung (Mien as well as Hmong), but also upland Tai, the Phuan of Xiang Khouang and the Phu-Tai of east central Laos.” (Stuart-Fox, 1997: 139)

Military Region II (northeastern Laos) bore the brunt of the war for almost fifteen years. Nearly 80% of the refugee population in Laos originated in MR II, including the refugees on the Vientiane Plaine. Almost the entire population of Houa Phan (Sam Neua) and Xieng Khouang Provinces were gradually forced south into the Long Tieng, Ban Xon, Muang Cha crescent.” (USAID, 1976: 210)


Displaced Hmong in Laos, probably in the early 1970s. Source: Roger Warner. 1998.

Displaced Hmong in Laos, probably in the early 1970s. Source: Roger Warner. 1998.


A consistent feature of war is the harming of civilian lives. The extent of harm is not always easy to ascertain, but is sometimes quantified in the number of “excess deaths” that occur during a war. For example, Hagopian et al (2013) surveyed two thousand randomly selected households throughout Iraq, interviewing residents about their family members before and during the US-led invasion and occupation. They estimated that from March 2003-2011 approximately 405,000 deaths occurred as a result of the war, mostly from violence.

However, such studies always have limitations – recall bias, survivor bias (the dead cannot be interviewed), and logistics in surveying high violence areas – meaning that mortality estimates will never be perfect, and Hagopian et al. gave a range around their figure (a 95% uncertainty interval of 48,000 to 751,000 excess deaths). Whatever the exact number, which we will probably never know, we can still be confident that mortality rates increased during the war years.  

The same challenges apply to all wars, including one that I have been interested in for a while – the Second Indochina War in LaosThe Australian historian Martin Stuart-Fox wrote that: “loss of life can only be guessed at, but 200,000 dead and twice that number of wounded would be a conservative estimate” (1997: 144). Mortality estimates for Laos are further complicated by the fact that it was one the least developed countries in Asia at the time of the war, likely with unreliable census data and other record keeping (though, for those who are interested, see the 1961 Joel Halpern “Laos Project Papers” from UCLA, which contain demographic and health statistics).

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Infant Mortality Rates, War & Laos

I finished my dissertation on how the war in Laos was correlated to the physical growth of Hmong refugees in 2004. The general idea was that early stressors, particularly prenatally and in infancy, can have long-term impacts on growth and health. The model I was working with came largely from David Barker’s (and others’) ‘fetal origins hypothesis,’ based on evidence that low birth-weight infants tended to grow up to have higher rates of things like type 2 diabates, coronary heart disease, hypertension, etc. A classmate in graduate school, Stephanie Rutledge, introduced me to Barker’s work and told me that I’d find it really enlightening. I did. Sadly, Barker passed away earlier this year, but his work helped spawn a new direction in research. 

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Bombing of Laos, Animated

The organization Legacies of War shared this animated video on the impacts of U.S. bombing of Laos during the Vietnam War. I thought the filmmaker, Corey Sheldon, put together a very attractive and informative video, although the history is perhaps understandably simplified. Today, the remnants of unexploded bombs are still a problem in Laos, decades after the war has ended, so I think projects like this one are helpful in raising awareness, particularly in the United States.  <div style=”text-align:center”>


Related posts

The Lingering Effects of the War in Laos 

Laos: The Not So Secret War 


One Planet. One Species. Homo sapiens.

“One planet, one experiment.”
………………..— Edward O. Wilson. 1992. The Diversity of Life.

Hadzabe men (wikimedia commons)

The BBC has compiled what looks to be an absolutely visually stunning television series, titled ‘Human Planet.’  The footage is said to contain video from 80 different locations, highlighting the relationship of humans to various ecological conditions.1 The description from the website:

Uniquely in the animal kingdom, humans have managed to adapt and thrive in every environment on Earth. Each episode takes you to the extremes of our planet: the arctic, mountains, oceans, jungles, grasslands, deserts, rivers and even the urban jungle. Here you will meet people who survive by building complex, exciting and often mutually beneficial relationships with their animal neighbours and the hostile elements of the natural world.”

Have a look for yourself at the preview:

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