The US Virgin Islands: The Ninth Ward of 2017?

In their recent article, Dzau et al. optimistically looked to Hurricanes Harvey, Irma, and Maria as possibly providing opportunities for rebuilding communities in Texas, Florida, and Puerto Rico in ways that will better promote population health than before the disasters.¹ They pointed to the Louisiana Health Care Redesign Collaborative, which was established after Hurricane Katrina, as a model, noting the poor state of population health in New Orleans, Louisiana, before the storm, and apparent improvement in care delivery by 2010. In the case of New Orleans, the disaster revealed in a glaring manner the role African American race played in determining the social determinants of health before the storm and, hence, the vulnerability to death, disease, and displacement from the storm.

As indicated by the failure of the authors so much as to mention the US Virgin Islands (USVI), another isolated population of American citizens of African descent, I fear that 2017 hurricanes may not stimulate rebuilding for better health there. The media provide daily updates on the unfortunate situation in Puerto Rico but almost never mention the USVI. Even a cursory examination of levels and trends in population health indicators in the USVI indicates poor population health there even before 2017.

The Global Burden of Diseases, Injuries, and Risk Factors 2016 Study has published estimates of mortality, prevalence, and disability for 265 causes in 195 locations including the USVI.^2–4 Age-standardized estimated death rates per 100 000 in 2016 were 813 (95% uncertainty interval [UI] = 731, 884) in USVI, 1404 (95% UI = 1214–1614) in Haiti, 570 (95% UI = 528, 616) in Puerto Rico, and 578 (95% UI = 569, 587) in the United States. The study also estimated a summary measure of disease burden, disability-adjusted life years as the sum of estimated years of life lost and years lived disabled. Age-standardized disability-adjusted life year rates were 27 871 (95% UI = 24 329, 31 701) in USVI, 50 580 (95% UI = 43 520, 58 404) in Haiti, 23 182 (95% UI = 20 300, 26 492) in Puerto Rico, and 23 975 (95% UI = 21 014, 27 323) in the United States. In 1990, the rates in the USVI were 925 (95% UI = 853, 977) for death and 31 145 (95% UI = 27 933, 34 440) disability-adjusted life years.

The much higher mortality and overall disease burden in the USVI as compared with Puerto Rico and the United States before the 2017 hurricanes points to the dire need for disease prevention and health promotion efforts for the more than 100 000 residents there, similar to those described by Dzau et al. in New Orleans after Hurricane Katrina and advocated for Texas and Florida.