Leading article Hurricanes and child health: lessons from Cuba Deybis Sánchez Miranda,1 Imti Choonara2 HURRICANES A hurricane is a large rotating storm with a central area of very low pressure and strong winds greater than 74 mph (118 km/h).1 The hurricane is graded 1–5 in relation to the strength of the winds, which can be greater than 155 mph (249 km/h, category 5).2 Hurricanes arise from warm, moist air from tropical oceans, and with global warming, hurricanes are occurring more frequently and with greater severity.3 Tropical storms originating in the Atlantic Ocean or the Eastern North Paciﬁc Ocean (ie, the Northern hemisphere) are termed hurricanes, whereas those that origi- nate from the Paciﬁc Ocean are known as typhoons and those from the Indian Ocean as cyclones.1 Hurricanes are a major problem for countries in the Caribbean and Central and Latin America. The word ‘hurricane’ is thought to be derived from either the Carib god ‘Hurican’ or the Mayan god ‘Hurakan,’ who caused a great storm and ﬂood by blowing his breath across the ocean.4 HEALTH EFFECTS It has been estimated that almost two million people worldwide have died from tropical storms (hurricanes, typhoons and cyclones) in the last two centuries.1 In the 20th century alone, there have been 75 000 deaths from hurricanes in North America and the Caribbean, including almost 10 000 deaths from hurricane Mitch, which affected Central America in 1998.5 The impact of hurricanes on health can be divided into immediate and 1Children’s Hospital, Camagüey, Cuba 2Academic Division of Child Health, University of Nottingham, Derbyshire Children’s Hospital, Derby, UK Correspondence to Professor Imti Choonara, Academic Division of Child Health, The Medical School, University of Nottingham, Derbyshire Children’s Hospital, Uttoxeter Road, Derby DE22 3DT, UK; imti.choonara@nottingham.ac.uk 328 during the recovery phase. Drowning during the hurricane used to account for the majority of the deaths. The use of warning systems combined with evacu- ation has, however, dramatically reduced drowning deaths.1 3 During hurricane Katrina, however, two-thirds of the fatalities were thought to be due to the direct physical effects of the ﬂood, and the majority of the deaths were thought to be due to drowning.6 The high num- ber of deaths due to drowning follow- ing hurricane Katrina was probably associated with the inadequate evacua- tion and preparation of the population.7 Hurricanes also cause death by physical damage to buildings and trees, which may result in direct trauma. The most frequent injuries following hurricanes are cuts, lacerations, puncture wounds and blunt trauma caused by ﬂying glass and other debris.1 8 There are signiﬁcant health effects after the hurricane when there may be a lack of clean water, food and housing as well as access to healthcare. The lack of provision of these essential items undoubtedly con- tributed to the signiﬁcant mortality fol- lowing hurricane Katrina.9 10 Infectious diseases may increase dramatically fol- lowing a tropical storm. This increase in infectious diseases is more likely to occur in low- and lower-middle income coun- tries. Damage to water and sanitation networks, alongside pools of stagnant water following ﬂooding, may result in a signiﬁcant increase in cases of gastro- enteritis and other infectious diseases. Hurricane Mitch resulted in increases in the number of cases of cholera, lep- tospirosis, dengue and malaria in sev- eral of the affected countries.5 Shelter for families who have been evacuated or whose homes have been destroyed is critical for survival. Fatalities following the cyclone in Bangladesh in 1991 were signiﬁcantly higher in areas where shel- ter was not provided.11 There is increasing recognition that following hurricanes and other natu- ral disasters, there may be signiﬁcant mental health problems.12 The most fre- quent psychological disorder following natural disasters is post-traumatic stress disorder (PTSD).13 Children appear to be more prone to PTSD than adults follow- ing natural disasters.12 The prevalence of PTSD appears to be related to the severity of the natural disaster and the proximity of the child or adolescent to the event.12 Studies in children follow- ing hurricanes have shown the preva- lence rate of PTSD has ranged from 7% to 90% in severely affected regions in Nicaragua following hurricane Mitch.14 The symptoms of PTSD can be present for a long period after the hurricane; 12% children had severe symptoms of PTSD 10 months after hurricane Andrew.15 It is important therefore to recognise that the health effects of hur- ricanes can last well beyond the initial period of impact. CUBA In the summer of 2008, over a period of 3 weeks, two category 4 hurricanes (Gustav and Ike) caused over 200 deaths in the Caribbean and the USA.16 17 The two hurricanes were at their greatest intensity (category 4) in Cuba and caused widespread destruction to buildings, livestock and crops. Hurricane Ike alone damaged over 300 000 homes in Cuba.17 Extensive damage to crops has been reported, and the economic cost to Cuba has been estimated as US$3–4 billion.17 The two hurricanes were of far lower intensity (categories 1 and 2) when they passed through Haiti and the USA. Despite the fact that Cuba experi- enced the hurricanes at their greatest intensity, there were only seven deaths throughout Cuba.16 17 In contrast, there were over 100 deaths in Haiti and over 30 in the USA.16 17 Over the last 50 years, Cuba has managed to reduce signiﬁ- cantly the number of deaths following hurricanes.18 19 Hurricane Flora in 1963 resulted in the deaths of over 1200 peo- ple in Cuba.18 Since then, Cuba has intro- duced early warning systems alongside evacuation. Hurricane Ike passed directly through the Province of Camagüey, and the steps taken to protect the health of children and adults are important for other countries. WARNING AND PREPARATION Because hurricanes originate in the mid- dle of oceans, it is several days before the hurricane reaches land, and this allows governments to take action to protect human life. Cuba has an excel- lent meteorological institute which, in conjunction with US scientists, projects Arch Dis Child April 2011 Vol 96 No 4