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Cuatro mil seiscientos cuarenta y cinco…

El pasado martes, 29 de mayo, el New England Journal of Medicine publicó un estudio conducido por investigadores de Harvard University, donde se estiman 4,645 muertes relacionadas al paso del huracán María en Puerto Rico.

He leído varios comentarios del público relacionado al estudio, algunos de los cuales cuestionan la veracidad de estos números, mientras que otros solo se enfocan en esta parte de los hallazgos. Aquí comparto mi opinión sobre los resultados del estudio y sus interpretaciones. Lo intentaré hacer de una manera simple, sin mucho tecnicismo, para que sea más fácil entender de dónde salieron los números estimados y cómo podemos utilizar esta información para mejorar nuestros sistemas de salud pública en preparación para próximos huracanes.

Sobre los métodos

Quiero empezar por darle un poco de contexto a la metodología que se utilizó para calcular estos estimados. Primero, el gobierno de Puerto Rico aparenta no haber querido compartir sus estadísticas con los miembros del estudio. Lamentablemente, esto es  algo bastante común en la isla… las agencias gubernamentales tienden a retener este tipo de información (por ejemplo, han sido extremadamente celosos con compartir estadísticas sobre las infecciones de Zika en la isla). Al no tener acceso a esta información, los científicos utilizaron métodos estándares para estimar muertes en áreas afectadas por desastres naturales. Este tipo de estudio se hace cuando no se puede llegar a todos en la población (primordialmente, porque es demasiado caro y no es costo-efectivo) y/o cuando no hay maneras concretas para calcular muertes exactas (ya sabemos lo difícil que esto se hizo en los meses después del huracán). Los autores dan ejemplos de estudios previos donde se han calculado muertes después de terremotos y otros desastres naturales; en estos casos, típicamente se trabaja por medio de encuestas para estimar muertes. Esta práctica es común en el mundo de la bioestadística y salud pública, donde se diseñan estudios para que los hallazgos puedan representar a toda la población. En este caso, la metodología que utilizaron los investigadores para seleccionar barrios y sectores en múltiples partes de la isla está basada en prácticas aceptables y comunes en el mundo de las ciencias. (Sin entrar en mucho detalle, identificaron y categorizaron barrios desde más cercanos hasta más remotos a ciudades con sobre 50,000 habitantes, y de estas categorías escogieron barrios al azar). De ahí, los investigadores pueden estimar muertes y otros factores al resto de la población.

Otra cosa sumamente importante es que los investigadores han permitido que sus datos estén disponibles públicamente, para quienes quieran hacer sus propios análisis. Para la comunidad científica, este nivel de transparencia es óptima en estudios donde se tienen que hacer ciertas suposiciones en los cálculos. De igual manera, los investigadores del estudio han compartido las preguntas que se hicieron en la encuesta (las puedes leer aquí). Estas son fáciles de entender y no requieren que los participantes hayan tenido que acordarse de cosas que pasaron hace mucho tiempo, lo cual minimiza tener respuestas erróneas en este tipo de estudio. También son muy transparentes en explicar las suposiciones que hicieron en sus cálculos, explicando cómo estas afectan los resultados. Los investigadores reconocen que hay varios factores que tuvieron que omitir, y es por esto que están abiertos a compartir sus datos para que otros investigadores puedan hacer estudios adicionales.

Sobre las muertes estimadas 

En el campo de la salud pública, pensamos tanto en lo micro, como lo macro. O sea, aunque nos interesa capturar las muertes inmediatas, también queremos saber cuántas muertes ocurrieron a causa de condiciones y/o falta de servicios ligadas al paso del huracán María. Los investigadores del estudio consideraron electrocuciones, interrupción de servicios médicos, complicaciones clínicas, suicidios y otros entre las causas de muertes atribuibles al huracán.

Según sus hallazgos, los investigadores estiman que las muertes por causas relacionadas al huracán entre septiembre y diciembre del 2017 pueden ser tan bajas como 793 y tan altas como 8,498. Aunque este es un rango bastante amplio, los investigadores fueron conservadores en sus cálculos, ya que no incluyeron posibles muertes en casos donde las personas entrevistadas vivían solas. En otras palabras, supusieron que ninguna de las personas en Puerto Rico que vivían solas entre septiembre y diciembre del 2017 murieron a causa del huracán. Hicieron esto porque es imposible entrevistar a personas que hayan vivido solas y fallecido a causa del huracán (ya que estarían muertas). Sin embargo, cuando hacen ajustes basados en las muertes que hubo en el 2016 en Puerto Rico para personas que vivían solas, sus estimados suben a 5,045… y al hacer ajustes basados en los tamaños de las familias en la isla, el total sube a 5,740. Nuevamente, los intervalos son amplios, pero siguen siendo números mayores a los reportados por agencias gubernamentales.

(Es importante recalcar que las cifras reportadas no son exactas, sino que son estimados. Las cifras están basadas en las respuestas que dieron los participantes, quienes representan al resto de la población en Puerto Rico.)

A las personas que hemos estado trabajando con comunidades remotas afectadas por el huracán, no nos sorprenden estas cifras estimadas. Muchos hemos escuchado historias sobre cómo el paso del huracán afectó el acceso a atención médica. Como un ejemplo personal, la tía de mi padre tuvo un accidente durante el huracán mientras ella estaba sola: una ventana se colapsó y le dio en la mandíbula, mientras ella intentaba mantenerla cerrada. Por meses después del accidente, ella tuvo muchos problemas para poder ingerir comidas sólidas, particularmente por el dolor que le causaba. Esto le causó una deshidratación y malnutrición severa. Falleció en marzo por fallo renal, después de haber bajado de peso a menos de 90 libras. Esta es solo una historia de muchas, por lo cual es importante no tan solo cuantificar casos como este, sino entender por qué sucedieron.

Sobre los demás hallazgos 

También quiero mencionar otros hallazgos del estudio que considero sumamente importantes, pero que a mi entender, no han recibido tanta atención en los medios. Aunque el propósito principal del estudio era estimar la cifra de muertes, también estima la cantidad de personas que emigraron a distintas partes a causa del huracán. Las cifras reportadas son muy similares a otros estimados y vislumbran posibles cambios en la tasa poblacional de la isla para el próximo censo. Y, claro, están las posibles ramificaciones políticas en los estados hacia donde emigraron estas personas.

Este estudio también estima la cantidad de personas y familias que estuvieron sin servicios de luz, agua y teléfono después del huracán. Me interesaría comparar estas cifras con las que reportó el gobierno local por medio de sus páginas de internet y la prensa local durante esos meses…

Finalmente, creo que es bien importante compartir que los investigadores incluyeron preguntas en su encuesta para describir qué tipo de problemas tuvieron las personas en obtener cuidado médico debido al paso del huracán. Según sus hallazgos, 31% de hogares tuvieron algún tipo de interrupción de servicios médicos. Entre estos hogares, aproximadamente:

  • 14% no tenían acceso a medicamentos
  • 10% no tenían acceso a carreteras
  • 10% no podían utilizar equipo respiratorio que requiere electricidad
  • 9% reportaron que habían facilidades médicas cerradas
  • 6% reportaron falta de doctores
  • 4% no podían costear gastos médicos
  • 3% reportaron problemas con transportación
  • 2% no pudieron comunicarse al 911
  • 1% tenían personas quienes no pudieron dializarse

Esta información le da contexto a las cifras de muertes reportadas en el estudio. Aunque los investigadores indican que no todas estas interrupciones necesariamente causaron muertes, sí ayudan a explicar cómo ciertos factores relacionados a falta de servicios clínicos pueden impactar a personas con enfermedades crónicas. Los investigadores no se limitaron a solo preguntar “sí” o “no” en cuanto a la interrupción de servicios médicos. Esto permite que futuros estudios puedan analizar los efectos que tuvieron los distintos tipos de retrasos en servicios en el total de muertes, al igual que otros factores capturados en la encuesta (como emigración).

Estos hallazgos también nos permiten tener conversaciones sobre cómo el huracán destapó problemas que llevan tiempo “cuajándose” en Puerto Rico, como diría mi abuela. Llevamos años discutiendo los efectos que el éxodo masivo de doctores y profesionales de la salud tendrá en la población de Puerto Rico, particularmente porque esta sigue envejeciendo y padeciendo de múltiples enfermedades crónicas. Mientras no se hagan esfuerzos para reponer y retener a doctores (y otros profesionales) en la isla, seguiremos sufriendo de estas situaciones.

En fin…

Los hallazgos de este estudio, por más limitaciones que tenga, tienen ramificaciones bien grandes. Aunque las encuestas siempre tienen ciertas limitaciones en comparación con métodos que utilizan actas de defunción para estimar muertes, los investigadores demuestran que sus extrapolaciones rindieron resultados comparables con estimados de la población durante otros años. En cierta forma, le dan veracidad a los hechos y confirman sucesos que antes pasaban como simples “anécdotas”… ¡y esto es importante! El trauma que el huracán ha causado no debe, ni puede ser ignorado. Confirmar estos incidentes por medio de estudios científicos nos permite, como pueblo, exigirle cuentas al gobierno y entender cómo podemos hacer mejoras públicas que impactan nuestra salud y bienestar. Además, creo que estos hallazgos demuestran que el gobierno no ha divulgado información suficiente (ni transparente) sobre las muertes y los efectos del huracán en nuestra sociedad. Estudios independientes, como este, son de suma importancia para entender los verdaderos efectos del paso de un huracán de esta magnitud en la isla.

Por mí, que venga el próximo estudio. Pendiente estaré a lo que reporten los investigadores de George Washington University…


Foto cortesía de Tostfilms 

Writer’s Block…

Inspiration, where art thou hiding?

Guys… I’m suffering from a severe case of writers block right about now. It could be that I am anxious about what the next few months hold, since I’ll be away from home working on my dissertation. It might also be that my current schedule has been making it hard to find the time to write. Or, let’s be honest: it may just be plain ol’ laziness.

It’s not that I don’t have things to write about… I guess I’ve just been lacking a little inspiration to get it all expressed in written form. I normally listen to podcasts that get me excited about certain topics (here and here are two of my favorites). I also like to read articles and essays that discuss growth and self-discovery – especially when they are written by people who have found it within themselves to share their views on life and all its intricacies. And, there’s my favorite movie of all time, Before Sunset, which always reminds me of the complexities of love, of living, and of sharing your deepest thoughts with people who bring out meaningful conversations. *Maybe I should write about that someday… 

But, like I said, I’ve hit a wall. I’m looking for some inspiration… and I’d love to hear what others have done to find it! Are there any books or pieces you’ve read recently that have inspired you? Any movies that have made you think about our fragility – or our resilience – as humans? Any podcasts or music worth listening to that give you a distinct perspective? Even better, is there anything you would like to read about here?

In the meantime, I’ll be watching Celine and Jesse wander the streets of Paris, talking about everything and nothing all at once… 💕

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Back at it

A lot can happen in a month.

When I started this very young blog back in the cold, snowy month of March (which feels like eons ago), I thought I would be able to write at least once a week. I figured it would be a way to channel my thoughts and process my emotions as life happens. However, the past five weeks have been pretty intense… not so much in the negative sense of the word, but in the pace at which things have been occurring. Ergo, writing here fell to the wayside.

I’m currently juggling several facets of my life that are all in alignment and important, yet managed to speed-up simultaneously. Since my last post, I was involved in back-to-back activities related to relief efforts in Puerto Rico post-María. I first moderated a panel discussion regarding the social, economic and public health impacts of the hurricane six months after its passing (it was really informative – you can watch it here). The following week, I took over my university’s Instagram account to share a fundraising event for community members in Sector Maná. Thankfully, both events were incredibly successful at raising funds and getting the word out about the needs Puerto Ricans are still facing. This also led to more exposure about PR Stands, which has brought about opportunities for new projects, partnerships, funding mechanisms, membership growth and other very exciting things that require lots of time and planning.

Yet, my month didn’t stop there. Simultaneous to the growth of our organization, the PhD side of things also picked up. I received IRB approval for my dissertation research, which is scheduled to happen over the summer in Tampa. With IRB approved, I finally had the green light to start planning my trip and data collection timeline. A few days later, I received the amazing news that I was selected to attend a summer program for doctoral students at the Oxford Internet Institute for two weeks this July… so I had to start scheduling that in as well. Then, another email came in: I had a manuscript I’ve been working on for quite some time accepted with minor revisions (finally!), which were due by the end of April. Oh, yeah – I also had pending data analyses for a study exploring Snapchat advertising among adolescents… plus two personal trips scheduled smack in the middle of April: one to Puerto Rico to visit my sister, and another week-long trip with my husband to New Orleans.

Needless to say, I’ve had a lot going on; so much so, that the end of March and beginning of April felt like a blur. I was going through the motions, but didn’t have the time to process and contextualize my emotions given the pace at which things were happening. The events related to PR relief efforts left me with conflicted feelings: I was elated that our efforts were successful and impactful, yet I was frustrated with the current situation in the island. I mean, just recently there were two major blackouts within a week of each other, and there are a myriad of social and political issues being trampled upon by the island’s current administration – which is why thousands are marching today. I was also really excited about the professional and academic opportunities coming my way, but felt anxious about getting everything done on time and in a way that meets my standards. It was a lot to try to put my finger on, and it took a bit of mental gymnastics to figure out how to manage it all.

Although things are not slowing down quite yet, I’ve managed to get a handle on the speed at which things are happening. How? This is what has worked for me:

(1) Make a list.

When things start to feel chaotic and messy, I try to realign myself by making lists of what needs to get done. It may sound somewhat mechanical or overly simplistic, but it really forces you to think about what it will take to get things accomplished and how much time is needed to do so. It also compartmentalizes your thoughts into plans that are easier to digest. Making detailed lists for each project has helped me identify what needs to be resolved immediately, and what can be tabled for later. It also lets me visually compare tasks and make a timeline; mine is currently out until the beginning of August. Now that I mapped it all out, it’s easier to tackle each day and build in time for myself. Personally, I use several journals and a weekly/monthly planner to break down my days and write down my thoughts as things come up. Whatever methods works for you, the most important thing is to remember that there are only 24 hours in a day – no matter who you are. So, manage them wisely.

(2) Say no.

One of the harder things in life is saying no, both to things that are out-of-scope and to people who take you off track. Again: our time is limited. Every thing you do takes up a portion of that time. Therefore, when you say yes to things and/or people misaligned with your goals, you are saying no to yourself. Recently, there have been several opportunities that I’ve had to politely decline because I knew that the quality of my work would suffer if I took on another project. And, even if the quality of my work didn’t suffer, my mental health would. Meeting other people’s deadlines and priorities at the expense of unnecessary anxiety and stress is not a worthwhile investment. I’ve also had to say no to people – those who truly matter will understand when you need to disappear for a while and take care of what’s important. Here’s a great essay on the need to say no.

(3) Surround yourself with similar vibes.

Energy flows from person to person. In my experience, this energy has the power to fuel you when life gets difficult. When those around you have ideas and priorities that resonate with your own, it’s much easier to stay motivated and use their energy to fuel your own. Being around friends with similar values has allowed me to stay concentrated on things that matter and refocus my energy on getting tasks accomplished. It also keeps me positive, which is so important when life starts to get stressful. Yet, not everyone has energy or values that align with your own; some people’s energy can be draining. It’s okay to remove yourself from this negativity, if it is starting to influence the way you approach things or the way you feel about yourself. It may be temporary, but it could well be permanent – that’s for you to decide. In the words of Joshua Fields Millburn, “You can’t change the people around you, but you can change the people around you.”

(4) Share your emotions.

With time, I’ve learned the importance of expressing my emotions when I start to feel overwhelmed. Doing so allows me to process things that don’t quite make sense. Sometimes this takes place in written form, when I start making lists and jotting down random thoughts. Other times, it’s more helpful to talk to someone who might be able to share valuable insight – or just lend a friendly ear. There are times when all it takes is listening to yourself say something out loud to find the answers you are looking for! That’s the great part of surrounding yourself with people who care and bring out the best in you: it is easier to share your thoughts and figure out how to best navigate present challenges. Regardless, my experience has been that the more you articulate situations and the accompanying emotions, the easier it becomes to identify how you feel about them. Getting clarity in this regard can help you figure out how to tackle what’s right in front of you.

(5) Take a break.

Seriously, find a way to stop the madness and center yourself. At first, I was somewhat anxious about my two pre-scheduled trips, because that was time I wouldn’t be able to get work done. Then, I decided to do the exact opposite: I did zero work those 10 days. Instead, I used that time to enjoy myself and let my mind relax. Rather than chastise myself for taking this time off, I gave myself permission to do something fun and soaked in every second of it. Whenever I started to feel anxious, I reminded myself I deserved to take a break. Once I returned home, I had the energy to hit the ground running with a new sense of clarity. Although I know it isn’t always possible (or realistic) to take a vacation when you need a break, it is feasible to take some time for yourself – exercise, mediate, sing, dance… whatever feels right. Do it – your mind will thank you!

It’s normal to feel overwhelmed when multiple things – good or bad – happen all at once. Instead of letting it overpower me, I’m embracing the ebbs and flows of life and findings ways to manage the things that matter. Taking this approach has allowed me to find balance and tackle things with a new sense of purpose.

And, before I knew it, time did its thing: it’s no longer snowing or 30 degrees outside. Instead, April showers brought beautiful May flowers… and lots of sunshine. Like I said, a lot can happen in a month!

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Six Months Later…

As I have mentioned in previous posts, Puerto Rico’s recovery in the aftermath of Hurricane María is far from over. Today we hit the six month mark of the storm’s impact, and there is still much to do.

As a founding member of Puerto Rico Stands, I have been working with members of the Johns Hopkins community to host several events to raise awareness about the public health needs still affecting Puerto Ricans. Check them out and see how you can help!


Tuesday, March 27, 2018 – Panel Discussion

Race in America

Johns Hopkins University (JHU) forums on Race in America is hosting the panel, Six Months After Maria: Public Health Issues in Puerto Rico. The following article by JHU’s The HUB outlines the current state-of-affairs and the topics to be discussed. Here is an excerpt of my interview:

“It’s important to continue to bring light to the issues that are happening on the island,” Rivera says. “We thought it would be good to do a follow-up six months later to remind people that the people of Puerto Rico are still facing days and nights without power, without running water, and without some of their basic needs met.”

[…]

She adds, “These are U.S. citizens, and they’re going through loss and mourning. It’s our job as public health professionals—and as citizens—to try to assist them in whatever way we can.”

I will be moderating the panel, so if you have any questions you would like addressed, let me know in the comments below!

Livestream broadcast can be watched here.

For free tickets via EventBrite, click here.


Monday, April 2nd, 2018 – Fundraising Event

Barranquitas

The majority of community members in Sector Maná and Sector Palmarito in Barranquitas, PR still lack power and running water. Others lost their homes and need assistance rebuilding. That is why Puerto Rico Stands and the Latino Public Health Network will be hosting a Food Expo to raise funds for this community. Although the event will only be open to members of the Johns Hopkins community, anyone can donate through our Go Fund Me page. Every dollar counts, so chip in if you want to directly help those impacted by the storm!

Funds will be used to purchase construction materials to rebuild houses, help bring power and running water back to the community, and assist in any other basic needs identified by community leaders from El Familión.


LPHN Food Expo


Puerto Rico will take a long time to rebuild, but if we start small and scale up, anything is possible. Thanks for being part of the solution.img_8313

“People are not built in silence, but in word, in work, in action-reflection.”

~Paulo Freire


Navigating that #phdlife: Why do you want a PhD?


PhD

Three simple letters with so much meaning. A terminal degree. Subject matter expertise. Street cred. The pinnacle of your academic training. For me, it’s the ability to finally become an academic researcher and a professor.

For as long as I can remember, I have wanted to pursue a career that would allow me to teach, mentor and explore new ideas. I was an extremely inquisitive child – I constantly sat in the front row and raised my hand to ask my favorite question of all: WHY. I also loved the feeling of creating something new, whether it be through dancing, singing, acting or writing. That is why it doesn’t surprise me that I gravitated towards research.

I distinctively remember being in a high school seminar where we were discussing what professions to explore in college. My hand shot up when they asked who wanted to be a scientist. Since I loved genetics, I was convinced my career goal was to pursue a PhD in Biotechnology. Why a PhD? Well, the few scientists I knew all had PhDs, so it was pretty simple: I need a PhD to be an academic researcher. The plan? Linear and concrete: Go to college, get a bachelor degree and go straight into a doctorate program.

my-path.pngFast forward to today: while I’m finally pursuing a PhD, my path was anything but linear. It took nine years after graduating from my undergraduate program to finally start my PhD. During that time, I transitioned from basic sciences to public health, got an MPH, and worked within multiple job settings: Lab Research. Federal Government. County Government. Academic Partnerships. Health Education. Even some retail and serving in between. Quite frankly, I wouldn’t have it any other way, because these experiences gave me invaluable insight… the exact insight necessary to once again answer the question:

Why a PhD?

If I’m being completely honest, knowing the answer to this question from the start is the key to a successful doctoral experience. Few people openly talk about the difficult aspects  of pursuing a PhD. And, guess what: It is scary, daunting, and by far one of hardest thing I have ever had to do.

Yes, pursuing a doctorate degree is an exciting, stimulating process. It is extremely rewarding to finally be immersing yourself in theory and literature, designing your own dissertation and pushing boundaries. However, it can also be incredibly lonely. Although your advisor is there to help guide you, you are expected to delve into a topic and become an expert on your own. On top of that, you will be partaking in required coursework, completing comprehensive exams, and most likely engaging in other research projects and extracurricular activities. So, finding a way to juggle it all, while also trying to keep your personal life afloat, is taxing.

In my case, I knew I wanted to pursue a PhD after exploring different career options and realizing I was happiest when I worked on designing and implementing new research projects, and while I was teaching. I am also extremely passionate about mentoring others. Academia offers a venue for me to do all of these things. Being clear and decisive about my reason to pursue a doctorate degree has been instrumental in staying motivated and making the journey much more manageable.

Will it be easy

Know there will be periods of darkness, frustration, and doubt. Every PhD student I know has gone through them, at least once. You will inevitably go through phases of the imposter syndrome, and don’t be surprised if you start questioning your beliefs and other aspects of life. If you don’t know why you are pursuing a doctorate degree, these moments will seem much more difficult than they actually are.

So, if you are genuinely considering a doctorate degree, I would encourage you to ask yourself the following questions:

  • Why do you want a PhD?
  • What is a PhD going to provide you that another degree will not?
  • What do you envision using your degree for?
  • Why now?

These questions may seem obvious now, but trust me when I say that this will be one of the most difficult phases you will ever go through. Write down your answers and revisit them every time things get challenging, lonely, or you start to question why you are doing this again (because, you WILL question it!). Having a clear end goal has truly helped me navigate my emotions during the process.

Also, be open to these answers changing slightly (or entirely) throughout your doctoral trajectory. Your personal journey may challenge you to reevaluate your end goals, or you may come across something new that inspires you to move in a different direction. The important thing is to have a reference point that will help you navigate your experience and allow you to constantly check-in with yourself.

To clarify, I am not trying to deter anyone from pursuing a doctorate degree. This period has been so fulfilling and I would do it again in a heartbeat! The road to getting a PhD has challenged me in so many facets of life, and has definitely made me a better, stronger version of myself. I only encourage you to make sure you know why this matters to you. Know your reasons for pursuing the degree and have them serve as an anchor and as motivation throughout the process. And, remember: there are no wrong reasons, as long as they make sense to you.

As for me, I’m less than 15 months away from graduating and achieving a goal I’ve had since high school. Although my path here couldn’t be farther from what I had envisioned, I’m sure my 15-year-old self would be incredibly proud.


I hope you enjoyed this first post on navigating the #PhDLife! To receive updates on future posts, follow my Facebook Page or sign-up for blog updates below.

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