Hurricanes, wildfires, power outages — disasters can strike anytime, anywhere. But how do they affect children’s health, and how can we better prepare? This episode looks at disaster response through a pediatric lens to highlight the unique risks kids face and the steps we can take to protect them.
We hear from Dr. Cindy Calderon in Puerto Rico, who shares lessons from Hurricane Maria and the 2020 earthquake, and Malia D’Alio from Seattle Children’s, who reflects on the 2023 Maui wildfires and the importance of community resilience.
Guests:
Cindy Calderon, MD, Pediatrician, Past President, Puerto Rico Chapter, American Academy of Pediatrics
Malia D’Alio, Manager, Workforce Community & Connection, Seattle Children’s
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer:
Each week, we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you are here, let’s go.
MUSIC:
Let’s go-oh-oh, Well Beyond Medicine.
Carol Vassar, podcast host/producer:
If you live on the East Coast like I do, you know that Atlantic hurricane season is officially here. It started June 1st, but natural and man-made disasters don’t wait for calendars, and they’re pretty geographically agnostic. Whether it’s wildfires or blizzards, earthquakes or power outages, or some other devastating event, they can have profound and lasting effects on the health and well-being of children. In this episode, we’re talking about what healthcare providers, pediatric healthcare systems, and families can do to better prepare for and respond to disasters.
To talk about this, I’m joined by Dr. Cindy Calderon, a pediatrician in Puerto Rico and past president of that island’s chapter of the American Academy of Pediatrics, AAP. She shares lessons learned during the island’s 2020 earthquake and during Hurricane Maria, which devastated Puerto Rico in 2017.
Audio / Video:
The first Category 4 storm to strike Puerto Rico in 85 years, slamming ashore around sunrise.
Hurricane came and took my house.
Carol Vassar, podcast host/producer:
Also joining me is Malia D’Alio from Seattle Children’s and the Western Regional Alliance for Pediatric Emergency Management. She’ll reflect on the devastation of the Maui wildfires that occurred in her home state of Hawaii in 2023, and what that disaster revealed about inclusion and community resilience.
Audio / Video:
Our house was gone. Everything that we had ever known was gone.
Everyone I know in Lāhainā, their homes have been burnt down.
It’s just scary to see a big wildfire just kind of coming your way, and it’s not something I’ve ever experienced before.
Carol Vassar, podcast host/producer:
Together, Malia and Dr. Calderon help us unpack the practical steps needed to prepare for and recover from disasters through a pediatric healthcare lens, and they’ll share a few lessons learned along the way. Here’s Dr. Cindy Calderon.
Dr. Cindy Calderon, Pediatrician and past president of the Puerto Rico Chapter of the American Academy of Pediatrics:
So, as a pediatrician, obviously, my major concern is for the pediatric population whenever a disaster hits. But as I heard one colleague in the past say, and I admire her explanation, Patricia Frost, when you work with preparedness and recovery for children, you work for the whole family. So what we faced after any experience that anybody can have in any part of the nation or disaster is our concern for the most vulnerable populations, and among them we know, besides the elderly, are children, very young children, pregnant women, and all of those patients that depend on technology to survive or who have chronic disease, which require medication, custom medication, or treatments that require electricity. And why? Because when a disaster…a natural disaster hits, one of the areas that is vulnerable and may fail is electricity. And along with electricity, everything else that complicates not having electricity is clean tap water and many other things that occur.
In our experience, Maria was a very strong hurricane. It was a major disaster, and we had populations, geographical areas in Puerto Rico who were without electricity up to 10 months. There were a lot of damage to the roads, the bridges, landslides, a lot of flooding, and all of these brought a lot of consequences and increased the risk of disease. So as a pediatrician, you start thinking, what do these families need to survive these circumstances?
And as a leader, what we did was moved towards the prevention of morbidity and mortality by proposing strategies that could be directed in the recovery and the mitigation of these disasters to help families be better prepared and be able to deal with the situations that they were confronting.
For example, I’m a strong advocate for breastfeeding, especially in islands. Why? Because when you have a large disaster that interrupts transportation into the island, as we had, the airports were shut down, the ports where the boats come in were also shut down, we know that we can have a deficiency of food, food insecurity. So, breastfeeding can be life-saving for infants.
So one of the things we did is together in collaboration with other groups like Americares, the Department of Health, the College of Physicians, and many other collaborators, was to promote breastfeeding among our mothers, the ones who were pregnant and newborns. We even had some initiatives to do relactation in those women that had recently stopped lactating because we knew how breastfeeding could be life-saving for that child. You don’t need to prepare a formula. If you don’t have clean water, you don’t need the clean water. What you need is water to hydrate the mother so she is well-hydrated and a lot of support so she can breastfeed. So another initiative related to that was that the ACOP was able to get a grant and deliver filters for women throughout the island so that they could have access to clean water to drink, because people were getting water from different sources, not necessarily the safest.
So that’s just one example of something that you can do. And to prepare these vulnerable populations, we’re always doing campaigns on how important it is for you to get well-prepared, to learn about breastfeeding, and to choose it as the best option, especially if you live in an island where the threat of hurricanes and other disasters may interfere with that aspect of feeding the infant.
Another example where we did a lot of work was teaching families. When you have a disaster, people are displaced. It can be a fire, it can be a hurricane, it can be a flooding. If they have to leave their homes, they have to go to shelters. The shelters may be a government-run shelter, or they may be with relatives, but the condition is similar. There’s usually overcrowding. And one of our concerns is infectious disease that spreads very fast when you have overcrowding.
So one of the areas which we gave priority was to educate the community leaders and the families to understand what measures they could take to protect themselves: hand washing, safe water, vaccinations against these common diseases like flu, and then when the COVID came, for COVID. So that was an area that we emphasized a lot. Other conditions that are very common in overcrowding are scabies, lice. So we gave them orientation on how to deal with these conditions, how to identify them so that it could be mitigated and families could live a better life. Equally, we also emphasize on the use of sanitary facilities, the importance of keeping them clean, washing their hands, identifying anybody who developed any kind of gastroenteritis to be sure that it’s not the water or if it’s contagious to take measurements to avoid, and how to manage these children so they wouldn’t dehydrate.
Carol Vassar, podcast host/producer:
You have lived experience in this area, Dr. Calderon. What gaps did you find that need to be mitigated as we move forward? How can we improve disaster recovery when it comes to pediatric healthcare?
Dr. Cindy Calderon, Pediatrician and past president of the Puerto Rico Chapter of the American Academy of Pediatrics:
In pediatric healthcare, the most important thing is continue to educate in prevention, in preparedness. If the families and community leaders understand well what steps they can take to prepare better, there’s going to be a better outcome. So we’ve given priority to that area. It’s not always the main priority of many agencies or many organizations because they tend to focus more on recovery and bringing aid, but the aid takes a little while to arrive at the local area.
So it’s really important to continue to educate and empower these community leaders and these families to deal immediately, to take precautions immediately when they are in the middle of a disaster to decrease mortality and morbidity, especially vulnerable patients. Patients that require dialysis, patients who have chronic conditions like asthma, patients with diabetes, they need to learn what are the basic ways for them to protect themselves, alternatives for treatment.
And the institutions and physicians, at least in Puerto Rico, we’ve learned so much. And every time there’s any kind of threat, my colleagues will honestly tell me, “I’m nervous already. I’m already calling all my patients. I’m already telling them you have to have this at home or you need to move closer to the hospital,” whatever is required to ensure that the treatment is not interrupted and that the patient has the best outcome.
Carol Vassar, podcast host/producer:
Malia, talk about how we can make sure that principles of inclusion are at the forefront of disaster planning, disaster recovery, and lessons learned after a disaster.
Malia D’Alio, Manager, Workforce Community and Connection, Seattle Children’s
I love this question because I think that there are ways that we can all work to even just reframe the ways that we think about and approach health equity in terms of, not just disaster planning and preparedness, but recovery, particularly for native and indigenous populations and communities, which are the closest to my heart and my work and my community. We are, in Hawaii, particularly with the Maui wildfires, we saw unfortunate, I think, examples playing out around health disparities that are just more pronounced for certain communities than others on a good day. Those tend to be exacerbated during times of disaster. And so it really was a lot of the communities that struggle on an average day to access housing, to have food security, to have adequate access to healthcare.
I think something that is a commonality or common thread that Dr. Calderon and I probably share around this is our island communities. Our island communities, whether you’re in the Pacific or whether you’re in any other area of the globe, they have to navigate very particular access issues. We only have one pediatric hospital to serve the entire state of Hawaii, and that’s located on the island of Oʻahu. And so when the fires broke out on Maui, there is a pronounced concern about there not being, not just access to the hospital itself, but trained staff who are specialized in pediatric care.
I think across the entire field of healthcare, those of us that work in pediatric medicine do a really good job at raising awareness and continuing to advocate to think about and include and adequately resource the unique needs of pediatric patients and populations. And that is something that I think, when we are going through a crisis and a disaster, and I’ve gone through COVID now and a couple of other emergency operations command center activations with my organization, and we tend to default to the partners, we tend to default to the collaborators who are on our radar from a day-to-day basis. And I think that the partnership and the relationship building, specifically with native and indigenous communities, doesn’t happen on the level that it probably needs to as part of our disaster readiness.
Carol Vassar, podcast host/producer:
It sounds like a lot of listening needs to take place in all communities.
Malia D’Alio, Manager, Workforce Community and Connection, Seattle Children’s
A lot, a great deal.
Carol Vassar, podcast host/producer:
Let’s talk about communication. How critical is communication between pediatric health systems, local authorities, schools, other community partners during disaster recovery, and what strategies are in place to ensure a cohesive response? Malia first, and then Dr. Calderon.
Malia D’Alio, Manager, Workforce Community and Connection, Seattle Children’s
I think that the first conversation that we need to be having about this is truly with ourselves. I think that there is, in my experience, in my observation, an eagerness from a lot of our healthcare partners, because we’re all healers in our own right, to go in and get the answers that we need from the community. But I think that the way that we often approach that, and part of it’s just because of the way that our systems are set up, and a lot of the institutional frameworks that are almost invisible to us working within the systems can actually do additional harm to the communities.
Cultural humility is a framework that I firmly believe that we all need to integrate into our own aperture of healthcare. I think that it has to start with being really honest and unpacking the ways that our biases, our intrinsic biases, are implicit or explicit biases towards the communities that we actually serve. And looking at the numbers, looking at the healthcare outcomes to kind of help keep us honest with ourselves about the direction that we’re going in, and really doing our work. I think the way that I like to frame it is cultural humility is your H&P, your history and physical, for your community.
The communities that we serve, especially those that are already experiencing pronounced disparities, their crisis didn’t start at the time of the disaster. That just became a different tipping point for them. And I think that, when we look at healing, we have to look at it longitudinally. We have to look at the fact that it isn’t just about meeting the immediate needs of the crisis. But how do we make those communities whole again? How do we ensure that we are debriefing with them to learn what we needed to learn in terms of the ways that we interceded during those emergencies in terms of the resources that we did or didn’t make available to them or did or didn’t prioritize for them during the time of crisis so that we are able to make all of our communities healthier in that way?
That doesn’t just apply to native and indigenous communities, but I think particularly so because they are displaced within their own land. This is their home, and this is where our ancestors have always been. We don’t have anywhere else to go. So we have to ensure that the land rights, that the resource rights, that the access rights of our people are centered, even by those that don’t share the identities that we do.
Carol Vassar, podcast host/producer:
Dr. Calderon, follow up with your take on the communication piece and the importance of listening, the importance of communicating during and after a disaster.
Dr. Cindy Calderon, Pediatrician and past president of the Puerto Rico Chapter of the American Academy of Pediatrics:
I agree with Malia on the importance of cultural sensitivity. Even on our island, we have different groups because some areas are more geographically isolated than others and they tend to create these subcultures. So it’s really important when you reach out to help others. The first question has to be, what do you need? It’s not what I think you need, but what do you really need? And that’s a very important conversation to have.
For that conversation to occur, you have to have a network of communication. So in this work of preparedness, recovery, mitigation, you have to establish this network prior to a disaster, and that’s an ongoing work, and you establish that network with everybody. I think as pediatricians, we have an important role integrating all these different collaborators into working towards the priorities of families and children.
So I can say (from) my own experience, I was fortunate. I was working in the Department of Health as a consultant with Mother/Child Health Division. I was a leader in the AAP. I had a lot of connections with other organizations that were very important, bringing aid, and I served as a voice to give out what was really going on and what we really needed. And that conversation continued, and it included daycare centers, it included school staff, because everything is affected. So right now we are going to go into a conversation of, this would be a long conversation of all the strategies that were proposed and done and the many gaps that we found. But I think overall, we all learned a little bit more the importance of communication and identifying what are the real needs of the community.
And in that process, you have to go out to the community. It’s not something you do on paper or something you do virtually. You need to visit them, you need to know them, and you need to go down, like Malia said, at their level so that communication is clear. You need to understand what are their real needs, how they feel, what are their priorities so that we can be more effective in helping them prepare. And sometimes these leaders are not necessarily persons who are in a position of power in an organization. Sometimes it’s just that person in the community who really moves around and knows everybody. And especially during after Maria, these were the ones who really helped the communities to be able to survive. I mean, if you live six months without electricity and with difficulty getting food, these were the leaders who were able to reach out and bring in what was needed. So that’s a very important aspect of anything that has to do with assist.
Carol Vassar, podcast host/producer:
I want to bring in the mental health piece here. I’m curious as to how pediatric health systems integrate the mental health support that’s so needed for children and families into disaster recovery planning. And why is emotional care, I’m curious about this as well, particularly important for children after disasters? Dr. Calderon.
Dr. Cindy Calderon, Pediatrician and past president of the Puerto Rico Chapter of the American Academy of Pediatrics:
Well, in disasters, not only the child, it’s the whole system. You, as a physician, as a person, as a family member, will be affected by whatever disaster occurs, and then you have the families and the impact it has. When we had that terrible Hurricane Maria, we were already in the internet era, and there was a lot of information. But immediately after the storm, we did not have internet. We had very poor communication. It was all down on us. It wasn’t able.
But as soon as we got it, I started looking as a professional. What do I have to aid my families who are so impacted emotionally from what’s happened? And I was very fortunate to find some very good resources from the National Children’s Trauma Center. Dr. Chandra Ghosh had written this coloring book that helped parents understand the changes in children’s behavior after a traumatic event, such as a hurricane, and how to deal with it, and it had a story that children could color with their parents and read, and were able to ventilate all these emotions.
When I realized this book was very useful, I communicated with the trauma center, and they were very glad to help us. So we were able to bring the book, and one of the organizations, United Way de Puerto Rico, adopted the book and printed it. And we did workshops for teachers for families on how to use the book, and we promoted it throughout the island. More than 6,000 books were sent out and were used.
Now, it’s not just a book, it’s the process. We have continued to give and empower families and caretakers on the importance of the impact of trauma and the importance of having care that is related to that, what we call relational care. We’re training pediatricians to understand this also because these are strategies that help families cope, help families empower, and help these families increase the resilience of their children.
And it’s really important because we know the long-term effects that all this trauma has and these emotions have on children. We are not talking about a post-traumatic stress syndrome as such because everybody had some event, had some degree of trauma, and we lived it for months.
I remember in one of my workshops, we had a family, a mother and a child, that what we did, we would give them out the books and we would tell them to color their favorite scene so they could share with each other how they felt about it. And this mother was coloring one page, and she started crying. She was still emotionally very burdened with everything that happened. And her child was four years old, went up to her mom and started passing the hand, said, “Mom, mom, relax, calm. It’s over. We’re all fine.” And it was such an emotional moment for all the other participants because they could feel that child has developed resilience. The mother is just reviving and trying to control her emotions.
So we understood we have to continue with this work. It’s on a long-term work, and there’s a lot of other groups that have come in and helped at the level of the schools in different levels, different strategies, to help people cope and become more resilient after trauma.
Carol Vassar, podcast host/producer:
As we look forward, we have all of this experience with disaster. There will be disasters to come. How can healthcare policies better address the needs of children in disaster recovery plans? Dr. Calderon.
Dr. Cindy Calderon, Pediatrician and past president of the Puerto Rico Chapter of the American Academy of Pediatrics:
Yes. I think that many changes have occurred, and many changes need to continue. Children with vulnerable conditions, for example, there has been the development of policies to help these families prepare better. For example, they are starting to get systems based on solar energy so they don’t have to depend on electricity, and they’re helping these families get these incentives and subsidies so they can get systems. These are families that we know usually have lower incomes because of all the situations. There’s other policies to help once the disaster occurs. Immediately liberate many of the authorizations or pre-authorizations, so families and children can continue to receive their care without the limitations that sometimes occur with these systems that are in place to control the use of these systems. So that has been helpful.
There’s even been change in treatments. Now we are teaching patients with asthma to use non-electrical devices to get their inhalation therapies. They don’t have to depend on electricity to get it. And these are changes in practices and changes in policies that occur because for them to get these other apparatus, the policies have to change to authorize them getting them. So they might seem like little changes, but they have a big impact on the morbidity and mortality of children when these disasters occur and the system is interrupted.
Carol Vassar, podcast host/producer:
Malia, any thoughts policy-wise?
Malia D’Alio, Manager, Workforce Community and Connection, Seattle Children’s
Yes. I would say that one of the ways that not just healthcare policies specifically would apply in terms of how we can improve the needs of children and disaster preparedness, but really a lot of the partners that end up convening on the communities to help with that immediate disaster response need to have plans in place ahead of time. I think there’s a lot more that we can be doing to talk through and scaling for something as simple as how we are going to stand up our food distribution centers, how we are going to be allocating funds to the communities.
In Maui, there was a huge influx of donations that came in. And I know that the state really worked very hard to try to mobilize with the feds in terms of getting the monetary resources to the community that they needed, but hadn’t thought through things as simple as, “How are we going to distribute those funds?” And so having something as simple as a debit card system set up to be able to get the money directly in the hands of the families when they need it. Even something like deploying the nonprofit organizations, a lot of them receive a huge influx of funding during times of disaster that come in through the communities. And sometimes they don’t always have a plan in place for how those funds are going to be utilized.
And housing is something I think, especially where we’re talking about communities that are geographically isolated and also have a limited amount of just land in general, and housing is an issue. Housing security is an issue for those communities on a day-to-day basis. When you’re talking about a massive number of community members, children, and families being displaced simultaneously, standing up and finding adequate housing for them was something that became very, very challenging for the state to resolve. And so looking at, I think practices like short-term housing policies at the state level, there were a lot of Airbnbs that were occupying and kind of encumbering the availability of housing resources for families on Maui. And that’s something that the state had to step up and address, and I think there’s a lot of lessons that we can learn from that moving forward.
Carol Vassar, podcast host/producer:
If you each had one thing to recommend to families to better prepare them for disaster situations with regard to the health and well-being of their children, what would it be? Dr. Calderon.
Dr. Cindy Calderon, Pediatrician and past president of the Puerto Rico Chapter of the American Academy of Pediatrics:
In Puerto Rico, we’re always communicating to the families the importance of preparedness. It was before Maria, and it continues after Maria and after the earthquake, because we are in a very high risk for seismic activity, for hurricanes. And we are an island, we’re isolated. We know that we need to deal with our problems immediately to save lives, while the aid cannot reach us.
So we’re always telling families, you need to be prepared, you need to do it in a family. Everybody has to participate. Everybody has to have a role and know well what his role is. They have to have clear plans where they’re going to go, how are they going to communicate, how are they going to get together again? If there is somebody who has a chronic illness, they have to know their medical history. They have to have evidence of all their prescriptions. They have to have medication for the season of hurricanes. We always tell them, you have to have extra medication at home. So we learned from the past, they have to have water, they have to have non-perishable food. That’s part of everyday living from June to November in Puerto Rico because we are an isolated area.
For other families in other areas, they have to realize what are the real threats to them, and they have to be prepared. They have to be prepared in different aspects, even emotionally, how you deal with your children during the disaster and after the disaster.
And then I want to recognize the role that the AAP as an organization has had supporting us, not only with funds, but with the expertise of all our colleagues, especially on the Council on Children and Disasters. They’ve always been there for us, and they helped us. Throughout all these disasters, they supported us. And beyond, it’s not just the funds, it’s just having a colleague that calls you up and says, “How are you? What do you need?” And giving you advice so that you can go on and do your work and feel good about it.
Carol Vassar, podcast host/producer:
Very comprehensive answer. Malia, anything to add?
Malia D’Alio, Manager, Workforce Community and Connection, Seattle Children’s
I would offer that, when we’re talking about community engagements, what we’re really talking about is relationship building, and relationship and trust building take a very long time. It doesn’t happen overnight. At the same time, that trust can be lost very quickly. It takes very little oversight-wise on our part as the agencies that are supporting the needs of our communities and our patient populations to break and harm the trust that we have with them, and it takes a very, very long time to rebuild that. And so for me, the work doesn’t just happen during the point of crisis. The work happens in between. Now is the time for us to be working on bridge-building and relationship-building in authentic ways.
Carol Vassar, podcast host/producer:
Malia D’Alio is with Seattle Children’s. She also works with the Western Regional Alliance for Pediatric Emergency Medicine. We also heard from pediatrician Dr. Cindy Calderon, past president of the Puerto Rico chapter of the American Academy of Pediatrics.
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Well Beyond Medicine.
Carol Vassar, podcast host/producer:
Thanks to our guests, Dr. Cindy Calderon and Malia D’Alio, for sharing not only their expertise but also their lived experiences and their deep commitment to building healthier, more resilient communities, especially for children and families. And thanks, as always, to you for listening in.
Conversations on anything related to what happens outside the doctor’s office and affects children’s health, that’s what we’re all about here on the Nemours Well Beyond Medicine podcast. Do you have something on your mind that you think would make a great podcast episode? We are definitely listening. Leave us a voicemail on our website, nemourswellbeyond.org, or email us at [email protected]. The website is a phenomenal resource to find all of our previous podcast episodes, leave a review, and subscribe to the podcast. Again, that’s nemourswellbeyond.org. You can also find the podcast on your favorite podcast app and on the Nemours YouTube channel. Thanks to our production team for this episode: Susan Masucci, Lauren Teta, Cheryl Munn, and Steve Savino.
Next time, we’ll explore a question that more than a few families are asking. Can herbs and supplements improve my child’s health? We’ll look at the science and the safety of this aspect of integrated medicine. Don’t miss it. I’m Carol Vassar. Until then, remember, we can change children’s health for good, well beyond medicine.
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Let’s go-oh-oh, Well Beyond Medicine.
