The Forgotten Needs Of Refugees From Hurricane Irma

In the small clinic where I work in Boston, it is rare to see a new, middle-aged patient who has yet to see a doctor in this city. Trust me — we are everywhere.

So when I saw an unfamiliar woman's name pop-up on my list for the afternoon, I was surprised to find an otherwise empty medical file. A recent transplant to Boston, I guessed.

That turned out to be all too true. The woman had lived the majority of her life in St. John, one of the beautiful U.S. Virgin Islands that sustained severe damage from Hurricane Irma. As we began talking, she retold the details of her journey in a small boat to Puerto Rico hours before the storm struck. She traveled with only a bag of her valuables and her beloved cat. (I'm not using her name to guard the patient's privacy.)

And now in Boston, she has to face the loss of her home, possessions, daily routines — and, as it turns out — her medical care.

Much media attention has centered on the immediate damage caused by the Category 4 hurricanes but less so on the long-lasting impact of these catastrophes and what they mean for people weeks, months, and years later.

When she presented to my clinic, her primary request was to be connected to mental health services to help cope with the severe trauma that she underwent. Obtaining health insurance was especially challenging, taking nearly five weeks before she was eventually signed up with MassHealth, the state-sponsored health insurance program. It took her nearly two months to have her first appointment with a mental health professional. She told me: "My life was planned elsewhere. Navigating the world here in the [mainland] United States. I still don't know what I'm going to do with my life. I don't know how to even begin to figure that one out."

That kind of disorientation is to be expected — and it doesn't necessarily go away after a few months. A study of 142 adult survivors of the 2004 Indian Ocean tsunami showed an 11.4 percent rate of post-traumatic stress disorder (PTSD) six years after the event.

The window of highest risk for developing PTSD was within one month after the disaster. But a quick response could be helpful. A study from Lorca, Spain, in 2011 examined the effects of a structured program that integrated mental health services into primary care clinics to anticipate the increased need for mental health support post-disaster after the earthquakes of May 11 that year. The results were promising, with significant improvement of symptoms reflecting anxiety, depression and PTSD.

Another new patient with no medical records, a man in his late 30s, arrived at my clinic with his wife a few weeks after I saw the woman from the Virgin Islands. He was walking with a slight limp, a smile on his face as he entered the exam room. I could tell he was happy — and would soon find that it was because he finally had a doctor again.

Displaced from his home of Puerto Rico because of Hurricane Irma, he and his wife moved to Boston to stay with extended family who provided them respite as they sought to re-establish their lives. Months earlier, he had suffered a severe fall in the bathroom of his home, causing short-term memory loss, difficulty with speech and movement and significant neck stiffness. He had been undergoing both speech and physical therapy in Puerto Rico, which he said had been greatly helping him to improve his neurological deficits.

When we first met, several weeks had already passed since he had come to the United States. One of his greatest challenges was obtaining his medications. "I was not able to receive my medication because the pharmacy in Puerto Rico did not have any communication with my insurance company there because the phone lines were down, so I had to pay out of pocket." he told me.

Once in Boston, he had to go to the emergency department at a community hospital simply to get refills of his prescriptions for his chronic medical conditions because of delays in establishing primary care.

"It's sad. I used to have a lot of communication with my doctor there," the man told me. "Now I have to start all over again."

Weeks later, I would find myself caring for a man in the emergency department who ran out of his anti-depressants when he was displaced by the hurricane. He expressed thoughts of wanting to end his own life to the attending doctors and had to be immediately evaluated by psychiatrists and placed on a medical hold.

What I have come to understand is that the medical consequences of natural disasters extend beyond the immediate challenges that we often hear of. Yes, it is important to stem the transmission of infectious diseases, to address the loss of basic necessities and physical harm. But for the survivors, there are other critical medical issues: finding a new primary-care doctor, connecting with mental health resources, creating a new foundation upon which to live a healthy lifestyle. But these challenges are typically brewing under the radar.

And these repercussions know no borders. The problems are equally true for Hurricane Irma survivors in the United States as for victims of the Bangladeshi floods of last summer, which caused emergency relocation and resettlement of nearly 50,000 people.

We must be vigilant in connecting refugees from natural disasters to primary care and mental health services quickly. Weeks after our first visit, the Puerto Rican man told that he has restarted physical and speech therapy. He'll continue receiving medical care from a number of his new doctors here in Boston.

When asked how he feels now, he responded: "I feel like I'm home."

Abraar Karan MD, MPH is a resident physician at the Brigham and Women's Hospital and Harvard Medical School. Reach him @AbraarKaran

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women's Hospital.

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