multitude of challenges. leptospira bacteria can survive longer at higher temperatures, with more human cases observed during summer months. increased rainfall and flooding associated with climate change opens up transmission pathways for leptospirosis and other zoonotic diseases, such as damaged sanitation and water treatment systems, flooded farms, and rodents or other animals seeking shelter and dry land. puerto rico is at a particularly elevated risk of infectious disease outbreaks related to climate change. the u.s. island's small size, remoteness from the mainland, low socioeconomic status, and high population density all magnify the population's exposure and susceptibility to illnesses like leptospirosis. as warmer air and water lead to increased precipitation and more energetic hurricanes, the island will need to adapt and build systems that mitigate climate-linked infectious disease transmission. public health officials will need to strengthen the essentials of urban sanitation as flooding not only overwhelms sewer and drainage systems, it also spreads garbage and debris throughout the environment that increases chances of transient contact between humans and animals. intensifying climate events and related environmental factors will continue to shape transmission of leptospirosis in places like puerto rico. surveillance and predictive modeling efforts utilizing geographic information science can help predict locations of future outbreaks with key factors, such as local infrastructure, rainfall effects, and human and animal population densities. braiding climate-informed predictive analytics with hardened water, sanitation, and public health infrastructure will be essential to prevent endemic disease in puerto rico from becoming seasonal high mortality events. this figure shows how environmental forces impact the transmission of leptospirosis. health care systems as a relatively small island with high levels of socioeconomic inequity before hurricane maria, puerto rico lacked a health care infrastructure that was capable of withstanding and fully responding to hurricane maria. beyond the destructive power of the storm and floods, weeks without power and clean water took an immense toll on countless patients and an already overburdened, overworked, and underpaid workforce. people with serious illnesses had their treatments interrupted for weeks, including many who required dialysis for kidney failure. disruptions in treatment for diabetes and other chronic illnesses underscore puerto rico's profound health inequities, thereby exacerbating the high rates of preventable and poorly treated physical illnesses linked to poverty, mental health and substance use issues in the aftermath of the hurricane. a key intersection of environmental and occupational health and leptospirosis prevention is the activity of health care, emergency response, and other disaster relief workers after heavy rainfall and flooding events. as paramedics, rescue workers, and residents wade through flood waters, they risk direct exposure to leptospira bacteria. this exposure can be mitigated with the use of protective clothing and gear, including proper coverage of wounds, but health care and emergency response systems in low-income urban environments often lack the awareness, training, and material resources necessary to put those precautions in place. proper bandages, waterproof gear, abrasion-resistant gloves, and face coverings help reduce leptospirosis infections among people who have to move through flood waters. prophylactic antibiotics to counter diseases like malaria and leptospirosis are also suggested for medical responders. the puerto rican government came under fire in the wake of hurricane maria for failing to provide protective equipment to relief workers who later contracted leptospirosis and died. for many puerto ricans with chronic illnesses, pharmacies were the first line of response to the disruption in health care services caused by hurricane maria, not primary care providers. pharmacists reported that a lack of telecommunications, electronic health records, and other essential data posed additional health risks. improving access to pharmaceutical services and removing bureaucratic obstacles to obtaining essential medications, including psychiatric prescriptions, is a key consideration in protecting public health in the face of growing weather and other disasters. socioeconomic factors leptospirosis transmission is shaped by the complex intersections of climate, geography, and socioeconomic factors. in places like puerto rico, these factors converge to disproportionately affect people living in poor, urban areas that experience warm temperatures and heavy rainfall. not only is the risk for leptospirosis in the environment higher in these areas, its potential deadliness as an infection is magnified by the adverse social determinants of health affecting people in these communities. studies in low-income regions throughout the world indicate that, even controlling for environmental factors, socioeconomic status plays a major role in risk for leptospirosis and the severity of its effects. communities with high levels of poverty experience higher likelihood of morbidity and mortality for leptospirosis attributable to relative socioeconomic status. to mitigate the risks associated with poverty, climate change, and endemic diseases like leptospirosis in puerto rico, the island's territorial government and the rest of the u.s. must address major underlying socioeconomic and political inequities. in workplace and shared public environments, many pathways for leptospirosis transmission can be addressed by waste removal and occupational health precautions. the prevalence of the disease in poor, urban areas complicates this approach, as private dwellings are more likely to become sites for contact between animals, contaminated water, soil, food, and humans. residents of these impoverished communities typically lack the resources to address such environmental risks individually, and adverse socioeconomic factors pose additional barriers to implementing widespread prevention strategies. many people in these areas also perform the majority of the labor to clean up in the wake of flooding, typically without any training or protective equipment. this cleaning activity has been shown to increase infections and spread leptospirosis throughout poor urban environments. in september 2018, millions of bottles of clean water from fema intended for hurricane victims were found on an airport runway in ceiba, apparently never distributed due to government mismanagement.