Enduring Impacts of the November 2021 Red Hill Fuel Spill: Health, Social, Economic, and Trust Implications

Executive Summary

On November 20, 2021, a jet propellant-5 (JP5) fuel spill from the Navy’s Red Hill Underground Fuel Storage Facility contaminated the Red Hill Shaft well. This well is part of the Joint Base Pearl Harbor Hickam (JBPHH) Drinking Water System within the Pearl Harbor aquifer on O‘ahu (Department of Defense Office of the Inspector General [DoD], 2024; Hawai‘i Department of Health [HDOH], 2023). After receiving complaints from water users on the JBPHH water system, on November 29, 2021, the State of Hawai‘i Department of Health (HDOH) issued a health advisory urging all in the area to stop using tap water. Consequently, approximately 93,000 people were potentially exposed to jet fuel for up to ten days (Navy Region Hawaii, 2025). Water supplied in the area was not deemed safe until March 2022, leaving people without access to safe tap water for over 100 days.

A few months after the spill, the State of Hawai‘i Department of Health (HDOH) and the Center for Disease Control Agency for Toxic Substances and Disease Registry (CDC/ATSDR) surveyed 2,289 residents, primarily through online questionnaires, to assess their health. They found that 86% of respondents reported new or worsening physical or mental health symptoms since the spill (Miko et al., 2023). Many also expressed frustration with poor communication and transparency, alongside distrust in the Navy (Parasram et al., 2024). A follow-up self-administered survey to 986 people in September 2022 found that 50% continued to experience worse physical health and 55% worse mental health since the incident (CDC/ATSDR, 2022; HDOH, 2022).

This report provides results from a follow-up self-administered online survey conducted in July 2023 (20 months after the spill) with 174 people who had participated in earlier CDC/ATSDR studies. The goal of this study is to understand how the disaster changed people’s daily lives, finances, and confidence in government agencies in addition to health impacts. Findings reveal significant and ongoing well-being impacts including physical and mental health challenges, disruptions to social networks and relationships, and financial losses. Respondents generally felt dissatisfied and betrayed by the Navy’s response to the crisis and pointed to how inadequate disaster response exacerbated well-being impacts. While the sample size (n = 174) limits generalizability, results provide insight into the range of ongoing well-being and trust impacts experienced by community members who drank water from the JBPHH water system during the Nov 2021 fuel spill, as well as how disaster response efforts can be improved in the future.

Nearly two years after the spill, most continue to experience physical, emotional, social, and/or financial impacts of this crisis. For many, trust in institutions, particularly the Navy, has been broken. A summary of main findings follows.

Ongoing physical and mental health impacts:

• About three quarters (79%, n = 137) of respondents reported one or more new or worsening physical and/or mental health symptoms since the 2021 fuel spill.
• A majority (68%, n = 118) reported ongoing symptoms in 2023, nearly two years after the spill.
• Nearly half of respondents (49%, n = 86) continued to suffer from mental health impacts followed by neurological symptoms (44%, n = 77), gastrointestinal issues (36%, n = 63), and skin/eye symptoms (34%, n = 60).

Healthcare response:

• The majority (65%, n = 110) of respondents sought medical care related to the spill.
• Experiences with medical care were mixed: 24% (n = 26) of respondents rated the medical care they received for their exposure to the fuel spill as excellent or good whereas 36% (n = 40) rated their care as bad or very bad.
• Over 50% (n = 87) of respondents said they have a great deal of trust in their health care provider to provide correct information; less than 5% (n = 6) said they have no trust.
• The vast majority of open-ended responses about health care described dismissed concerns, insufficient documentation of symptoms, inadequate testing options, and challenges accessing specialists.

Social and economic impacts:

• Many reported feelings of isolation as a result health impacts and inadequate disaster response.
• Some respondents also pointed to ways that the community organized and supported one another in disaster response.
• Some (18%; n = 31) reported income loss (median = $13,750 annual income), while the majority (82%; n = 142) incurred additional out-of-pocket expenses (median = $8,200).
• Only 12% of those with out-of-pocket expenses said they were fully reimbursed, and more than a third (36%) said they received nothing at all.

Institutional trust and perceptions of institutional crisis response:

• Respondents were most satisfied with how the Honolulu Board of Water Supply (BWS) responded to the crisis and least satisfied with the response of the Navy.
• Many expressed feelings of betrayal, particularly toward the Navy. Many respondents said they felt lied to about the safety of the water, and cited inadequate medical and other crisis response as factors undermining trust.
• Participants discussed a need for greater transparency, accountability, and empathy in future crisis response.

1. Introduction

Clean drinking water access is a fundamental human right and underpins community health and well-being, including physical and mental health, social connections, and material well-being (United Nations, 2024; Wutich et al., 2020; Beamer, 2025). Environmental disasters involving water contamination, whether episodic or ongoing, can have profound and lasting impacts on communities (Beckley-Jackson, 2017; Cuthbertson et al., 2016; Kruger et al., 2017; Parasram et al., 2024; Reuben et al., 2022). Research from the Flint, Michigan water crisis, where 100,000 residents were exposed to elevated lead levels in their drinking water in 2014-15, for example, documented serious physical health impacts as well as significant mental health consequences including elevated rates of depression, anxiety, and posttraumatic stress disorder (PTSD) that persisted for years after the initial lead exposure (Cuthbertson et al., 2016; Reuben et al., 2022). Mental health impacts were tied not only to the physical health impacts of the contamination itself, but also to the failed institutional response, with many reporting feelings of abandonment, anger, and distrust toward government institutions (Cuthbertson et al., 2016; Hamm et al., 2023). Economic analyses have further demonstrated how such crises can devastate property values and create cycles of disinvestment that compound community stress (Christensen et al., 2023).

Military operations have been a significant source of water contamination across many parts of the world. As a prominent example, between the 1950s and 1985, approximately 1 million people on the Marine Corps Base Camp Lejeune were exposed to drinking water contaminated with hazardous chemicals, including trichloroethylene, perchloroethylene, benzene, and vinyl chloride, leading to severe health consequences including cancer and birth defects (CDC/ATSDR, 2017; National Research Council, 2009a, 2009b). Across the Pacific Islands, military activity of the United States and other countries, particularly since World War II (WWII), has been a major source of water (and other forms) contamination (Naval Inspector General, 2013; Ruff, 2015). As of 2013, no overseas U.S. Navy drinking water system met U.S. compliance standards (Naval Inspector General, 2013). In Guam, for example, widespread use of Agent Orange, PFAS, and other toxic chemicals around Anderson Air Force Base and Naval Base Guam have severely contaminated soils and groundwater with documented health impacts (Denton et al., 1999; Denton & Sian-Denton, 2010; EPA, 2025; GAO, 1987; Noel et al., 2015). Similar contamination from military bases and operations has been reported across many Pacific Islands including the Northern Mariana Islands, Marshall Islands, Okinawa, and the Hawaiian Islands (Haddock et al., 2011; Mitchell, 2020; Mori, 2022).

It is within this context that there have been decades of calls from the public, civil society, the BWS, and others challenging the safety of this aging industrial facility that sits merely 100 feet over a sole source aquifer on O‘ahu, the most densely populated island of the Hawaiian archipelago (Yoklavich et al., 2015; Tanaka & Frietas, 2025). The facility consists of 20 underground fuel tanks built during WWII, and has a history of leaks dating back to 1947, just a few years after it became operational (Singh, 2024; TEC Inc., 2008; Yoklavich et al., 2015). Despite this, military officials had repeatedly assured the public that the facility was safe and did not pose a threat to drinking water or public safety (Jedra, 2021; U.S Navy, 2016).

On May 6, 2021, approximately 19,000 gallons of jet fuel spilled into a pipe in the Red Hill Fuel Storage Facility and remained there until November 20, 2021 when an accident caused the fuel to spray into a tunnel. It is estimated that up to 5,500 gallons was released, directly contaminating the Red Hill Shaft well, which supplies the Joint Base Pearl Harbor Hickam (JBPHH) Drinking Water System (Department of Defense Office of the Inspector General, 2024; HDOH, 2023). The State of Hawai‘i Department of Health (HDOH, 2021a) issued a “do not consume” order on November 29, 2021, after water users reported illness and fuel-like odors that the Hawai‘i Poison Center declared a sentinel event (Felton, 2022). While the Navy continued to minimize concerns (Cleveland-Stout, 2024; Jedra, 2023), water testing on November 29th, 2021 at Red Hill Elementary School found petroleum contamination. Additionally, testing of the Navy’s Red Hill Shaft on December 5th found total petroleum hydrocarbon (TPH-diesel) levels 350 times above the environmental action level of 400 ppb for drinking water (HDOH, 2021b). The following day the HDOH (2021c) issued an emergency order for the Red Hill facility to immediately suspend operations and install a drinking water treatment system at the Red Hill Shaft. Approximately 9,694 households and up to 93,000^[1] people who worked and lived in areas reliant on these wells may have been exposed to jet fuel in their tap water for ~10 days (Brewer, 2023; EPA, 2023; HDOH, 2021b; See Miko et al., 2023 for a complete timeline). In addition to population estimates, exposure assessment modeling suggests a range of possible contaminant concentrations and pathways, through tap water, sheens, emulsions, and vapor inhalation, demonstrating the potential breadth of exposure (Brewer, 2023).

In addition to public health impacts, the fuel spill also triggered significant legal and regulatory repercussions. Thousands of residents filed lawsuits against the U.S. government under the tort claims act, the Honolulu Board of Water Supply (BWS) sued the U.S. government to recoup some of the expenses they incurred in the aftermath of the water crisis, and the Department of Justice is criminally investigating events surrounding the spill and have indicted two civilians at the time of this writing (BWS, 2025; Feindt v. United States, 2025; United States v. Floyd, 2025). It was the sustained pressure from residents, workers, community members, and advocacy groups that prompted the decision to defuel and permanently shut down the Red Hill Bulk Fuel Storage Facility (U.S. Department of Defense, 2022)..

In the months following the incident, the HDOH and the U.S. Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR) conducted a convenience sample Assessment of Chemical Exposures (ACE) survey of 2,289 water users to assess immediate physical and mental health impacts (hereafter referred to as ACE 1) (Miko et al., 2023). In this study, 86% percent of respondents reported at least one new or worsening physical or mental health symptom since November 20, 2021. A follow up (ACE 2) study of 986 respondents, conducted in September 2022, found that 50% said their physical health and 55% said their mental health was worse at the time of the survey than before the incident (CDC/ATSDR, 2022; HDOH, 2022). More recently, a third ACE investigation (ACE 3) reviewed 653 military health records from individuals potentially exposed to the spill, covering the period from November 2021 through February 2023. Approximately half (55%) of the records documented worsening pre-existing or persistent new conditions or symptoms, which included migraines, chronic pain, headaches, anxiety, rashes, and fatigue (Nguyen et al., 2025). These findings raise concerns about ongoing physical and mental health impacts, while qualitative responses from the ACE 1 study also pointed to economic challenges, insufficient communication, broken trust, and other social repercussions (Parasram et al., 2024).

This report provides results from an online self-administered follow-up survey, conducted in July 2023, with a subset (n = 174) of the CDC/ATSDR ACE 1 & 2 survey participants. The survey focused on the physical and mental health, social, economic, and trust implications of the water contamination nearly two years after the November 2021 Red Hill fuel spill. Some questions were identical to those from the UHERO Rapid Health Survey (Juarez et al., 2022), a cohort sample of 2,030 Hawai‘i adults in 2022 gathered to study the longitudinal effects of COVID-19, to allow for comparisons between the two populations. As partners across the University of Hawai‘i system work to establish a Red Hill Registry, understanding the suite of impacts experienced by some of the users of the contaminated water will likely be of great utility (Red Hill Registry, 2024).

The objectives of this report are to:

1. Document the perceived social, economic, mental, and physical health impacts of the November 2021 Red Hill fuel spill nearly two years after the event; and
2. Document perceptions of the crisis response and resultant levels of confidence in various public institutions.

2. Methodology

In order to document a wide range of perceived outcomes of the Red Hill fuel contamination nearly two years after the event, we conducted a self-administered online questionnaire in July 2023 using a subset (n = 174) of JBPHH water users who had participated in the ACE 1 & 2  surveys. The CDC/ATSDR supported recruitment by sending an email to previous survey participants who had provided contact information (n = ~1,900). Of these, 174 people completed the survey, representing a nine percent response rate.

The survey was designed to understand a wide range of impacts as perceived by JBPHH water users and included both open-ended and closed-ended questions (See Supplementary Table 1 for a list of questions and numbers of responses to each question). The first set of questions on mental and physical health followed the general format used by CDC/ATSDR to facilitate longitudinal comparison. Additional questions on depression (Andresen et al., 1994) and self esteem from the were identical to those from the UHERO Rapid Health Survey (Juarez et al., 2022), a cohort sample of 2,030 Hawai‘i adults in 2022 gathered to study the longitudinal effects of COVID-19, to allow for comparisons between the two populations.

We also included questions about broad well-being impacts, including how the event had impacted their individual and household social and financial well-being as well as questions about perceptions of crisis response, levels of institutional trust, satisfaction with institutional response to the crisis, and any fear or concerns they have or continue to experience. These questions, primarily in Likert format, were coupled with open-ended questions about the respondents’ experiences, allowing for emergent themes and specific experiences to be documented. The survey followed Institutional Review Board protocol informed consent and participants received a $25 Amazon gift card.

2.1 Analysis

Close-ended responses were analyzed using standard descriptive statistics (e.g. standard deviation, median) and visualized as graphs. To evaluate significant differences in Likert-scale data, Kruskal–Wallis tests were performed with post hoc comparisons using Dunn’s test. Chi-square tests were used to compare responses with the UHERO Rapid Health Survey (Juarez et al., 2022). All analyses were conducted in R version 4.4.1.

Open-ended responses were collated by question and coded thematically using deductive and inductive coding using MAXQDA. All potentially identifying information was removed from open-ended responses before including in the report.

3. Results

The first section of the results provides the demographics of the survey sample followed by the second section on water use and concern over water safety over time. The third section shares quantitative and qualitative survey results related to overall household well-being, mental and physical health, economic impacts, and social impacts. The fourth section provides responses regarding perceptions of health care response, institutional crisis response, and levels of confidence and trust following the crisis. Finally, the last section shares respondents ideas on improving crisis response into the future.

3.1. Demographics of respondents

Of the 174 respondents, the majority (74%, n = 129) identified as female, followed by male (25%, n = 44), and non-binary (1%, n = 1). Age groups of respondents included 19–29 years (9%, n = 15), 30-39 years (34%, n = 59), 40-49 years (34%, n = 59), 50–59 years (14%, n = 25), 60–69 years (8%, n = 14), and 70 years or older (1%, n = 2). All respondents were 18 years or older, as specified in the survey design. Racial identification was predominantly white (74%, n = 133), with additional representation from Latino (12%, n = 21), Japanese (6%, n = 11), and African American (6%, n = 10) participants. Other racial identities include Hawaiian (3%, n = 6), Filipino (3%, n = 5), Chinese (3%, n = 5), Native American (4%, n = 8), Korean (2%, n = 4), and Samoan (1%, n = 2). The median household income of the sample was $105,000.

The median household size among participants was four individuals, with a total of 592 household members represented, of which, 39% (n = 229) were 18 years or younger, 58% (n = 343) were between the age of 19 and 64, and 3% (n = 20) were over 65 years old.

The majority (90%; n = 154) were directly affiliated with the military, including current service members (n = 49), dependents with a sponsoring service member (n = 93), and retirees (n = 12). Among active service members, representation was highest in the Army (39%, n = 19), followed by the Air Force (34%, n = 17), and Navy (20%, n = 10). Among sponsors, the largest affiliations were with the Navy (32%, n = 30), Army (29%, n = 27), and Air Force (28%, n = 26). Another nine percent (n = 16) said they had no affiliation to the military and two respondents (< 1 %) said they prefer not to say.

At the time of the survey, 37% (n = 64) of respondents lived outside of Hawai‘i and 51% (n = 88) had changed addresses since March 2022. Respondent distribution at the time of the spill was predominantly from Hickam Air Force Base housing, Aliamanu Military Reservation (AMR), and in Catlin Park and Moanalua Terrace communities, north of the Honolulu International Airport (Fig. 1).

Of the 169 respondents reporting health insurance coverage during the 2021 Red Hill fuel spill, the majority (83%, n = 140) were covered by military insurance, with Tricare Prime being the most common provider (62%, n = 105) followed by TRICARE Select (21%, n = 35). Civilian insurance providers included HMSA/Blue Cross Blue Shield (12%, n = 21) and Kaiser (5%, n = 9), while a small percentage of respondents had Medicare (4%, n = 7), Med-Quest (3%, n = 5). A small number of respondents (1%, n = 2) reported having no insurance coverage during this period.

3.2. Water use and concern over safety of water

“We will always fear the quality of our water moving forward, we will also struggle to trust the gov’t/military to act forthrightly and in our best interest.” ~ Survey respondent

Prior to November 2021, the majority (60%, n = 104) reported that they were not concerned at all about the safety of their tap water (Fig. 2). In contrast, from November through March 2022 (during the exposure window), the majority (77%, n = 133) said they were extremely concerned with no respondent saying they were not concerned at all.  While sentiment shifted towards less concern in 2023, nearly two years after the incident, only a small fraction (9%, n = 16) of survey participants said that they were not concerned at all, with the majority (75%, n = 129) saying they remained extremely concerned to moderately concerned about their water. At the time of the 2023 survey, those who had moved from their original home at the time of the spill felt less concern (p < .05) about the safety of their tap water compared with those who had not moved. 

Ninety two percent (n = 158) reported shifting to an alternative water source after hearing of the incident in November 2021. At the time of the 2023 survey, the majority of respondents continue to use an alternate soure of drinking water, including 84% (n=65) of those who had not moved and 73% (n=59) of those who had moved. 

3.3. Well-being impacts

3.3.1 Household well-being impacts

Survey respondents were first asked about impacts of the spill on their households’ mental health, physical health, recreation, finances, social interactions, and work/school success. Overall, respondents reported negative impacts for 91% of household members (541 of 592). Those under 18 were most affected (94%; 216 of 229), followed by adults aged 19–64 (90%; 310 of 343) and those over 65 (75%; 15 of 20).

In terms of the type of household impact experienced, mental health effects were seen as the most significant with 81% (n = 138) of respondents saying their household’s mental health was impacted or very impacted (Fig. 3). This was followed by physical health (73%, n = 124 reporting impacted or very impacted), recreation and finances (66%, n = 113 reporting impacted or very impacted for both categories), social interactions and work/school success (58%, n = 100 reporting impacted or very impacted for both categories) (Fig. 3). The majority of respondents indicated that all (30%, n = 52) or some (56%, n = 95) impacts to members of their household are ongoing.

3.3.2. Physical and mental health impacts

Overall, Seventy-nine percent (n = 137) of survey respondents indicated that they personally experienced a new or worsening physical or mental health symptom after the November 2021 spill. The majority (68%, n = 118) reported ongoing symptoms in 2023, two years after the event. Forty-two percent (n = 65) of those reporting a new or worsening symptom responded they were most confident on a scale of 1 to 5 (not confident to most confident) that their symptom(s) were related to the contaminated water, while just four percent (n = 6) said they were least confident (Fig. 4).

Consistent with the household reported outcomes, mental health (e.g., anxiety, sleep disturbance, agitation, depression) and neurological symptoms (e.g, brain fog, memory issues, migraines/headaches) were the most widely reported (with 49% and 44% of respondents continuing to experience these impacts, respectively). This was followed by gastrointestinal (e.g., diarrhea, nausea, cramps) and skin and eye symptoms (e.g., dry/itchy skin, rashes, burning eyes, redness), with 36% and 34% of respondents continuing to experience these impacts, respectively  (Fig. 5; Supplementary Table 2). See Supplementary Table 2 for a complete list of symptoms reported.

Related to mental health, 84% (n = 146) percent of respondents reported higher stress levels at the time of the survey – 52% much higher, and 33% somewhat higher – than before the spill. About half (51%; n = 81) reported feelings of depression at least once a week.

Compared to other Hawai‘i residents at the same time, Red Hill survey respondents were almost twice as likely to report depression and nearly twice as likely to report very low self-esteem. Specifically, compared to the UHERO Rapid Health Survey Cohort, significantly (p < 0.05) more Red Hill respondents had symptoms of depression (46% vs. 32%) and highly depressive symptoms (8% vs. 5%). In addition, the Red Hill survey respondents scored significantly lower on self-esteem with 19% reporting low self esteem compared to 11% in the UHERO Rapid Health Survey Cohort (p < 0.05) (Fig. 6).

Mental and physical health – qualitative responses

Open-ended responses (n = 50) to the question, “If you would like to, please elaborate on any health issues you or your family experienced since the fuel spill,” described a range of mental and physical health effects, including those on the pre-defined list (Supplementary Table 2) as well as additional conditions. For example, one respondent shared:

 “New diagnoses include: parasomnia, ocular rosacea, rigid muscles in the head, neck, and upper body. I see a therapist every two weeks for anxiety/depression/trauma. I take daily meds for seizures, rigid muscles, and anxiety/depression. My life has been forever changed for the worse.”

Another wrote, “my [spouse] almost died, [they are] still severely sick and under doctor’s care, medically disabled and doctor told [them] to move away to get away from all the contamination.” Others mentioned cancer diagnoses, kidney failure, severe and ongoing rashes, losing hair, migraines, among other health impacts that they believed were connected to the spill.

Many respondents expressed significant concerns about their children’s health. One participant shared, “My toddler had the worst symptoms. I’m not even sure if my newborn [child] (I was pregnant at the time) will have long-term symptoms.” Another noted, “The children were the worst affected, though we all got skin rashes, and the children’s skin has had patchy and sporadic rashes ever since.” Others described severe, perceived exposure-related impacts, including one who reported recently discovered bone tumors in their child, and another who wrote, “My [child] was born with a rare spinal defect. I [was pregnant] during the spill. We both suffered significant health issues still a year later.” A further respondent shared, “I cannot stress enough how worrying and horrible it was to see my [child] doubled up with pain in [their] stomach and having no clue what to do or why it was happening—and then finding out a couple of days later it was the water I was giving [them] that was causing the pain.”

Many respondents also described mental health challenges related to the trauma and uncertainty of the spill. In the words of one respondent: “Health issues for us were more in the mental health realm of anxiety and tension due to the uncertainty of what was happening and new info everyday, unsure of how to understand and react to all of the changes and different agencies involved.” Multiple respondents also referred to suicide and depression, including one who said, that “both my [spouse] and I experienced suicidal ideation for the first time in 2022.” In total, six percent (n = 10) of respondents reported having suicidal thoughts at some point between the 2021 fuel spill and the time of this survey in 2023.

Some spoke of how existing or feared physical health problems have triggered their mental health challenges. For example, one respondent shared: “my depression and anxiety have gotten worse as a result of the trauma of this incident. I fear I have an undiagnosed autoimmune disease and I fear the possibility of cancer in the future.” Others spoke of mental health challenges that go beyond physical health symptoms; for example, one respondent explained: “the physical impacts were immediate, but short-lived so far. The mental and emotional are what we still carry with us.”

Many respondents also described impacts to pet’s health, including death, kidney failure, and cancer. One respondent wrote,

“our [pet] died. [It] developed bladder problems when we moved into that house. Shortly after we left the island we found out [it] had megacolon, several bladder stones, a severely degraded spine, and a grapefruit sized tumor. It is so hard to not assume causation from Red Hill. We are very much traumatized.”

3.3.3 Economic impacts

A majority, 62% (n = 105), agreed or strongly agreed that the fuel spill had a negative impact on their household’s financial situation (Fig. 7). Twenty-six percent (n = 44) reported someone in their household experienced job loss or reduced work opportunities due to the spill, and 22% (n = 7) reported a loss in assets or property (Fig. 7). More broadly and likely related to the multiple health, social, and economic dimensions of the spill, 92% (n = 157) agreed or strongly agreed that at least one person in their household was affected by fear or worry as a result of the spill.

When asked about specific financial losses, 31 respondents (18%) reported direct income losses. Of those who provided specified their estimated income reduction (n = 18), the median value was $13,750, with one respondent losing as much as $140,000 in income. In terms of duration, about half of those who lost their income indicated that this disruption was temporary or moderate (less than one year) while the other half reported a duration of either more than one year or still ongoing at the time of the survey. One respondent reported that their spouse retired early and therefore lost the entirety of their income: “My [spouses]’s migraines and vertigo spiked significantly in August 2021. [They were] medically retired as a result and [are] unable to work and collect social security as a result.” Others rejected job offers or quit their jobs in order to leave Hawai‘i or were unable to work because of their health.

The spill also created hidden costs for the vast majority. Eighty two percent (n = 142) reported extra out-of-pocket expenses such as health care, water filtration, gas, and lodging. On average, additional household expenditures were $8,200 (ranging up to $74,000). Most of these expenses were not reimbursed; only 12% of those with out-of-pocket expenses said they were fully reimbursed, and more than a third (36%) said they received nothing at all. As one participant explained: “I have personally spent $18k or more on medical care for this debacle and am still not completely healed. It’s infuriating, like my life was robbed from me. I had zero medical conditions prior to this incident.” Another respondent shared, “I am thankful I had insurance yet sad and ashamed that I still struggle [because] I know many did not have insurance.”

Relocation was another major financial burden. Among the 137 respondents (77% of those surveyed) who relocated temporarily or permanently as a result of  the water contamination event, 55% paid upfront using personal funds, while 30% used a Government Travel Card. One respondent described the daily stress:

“It was so difficult to go back and forth from our house to the hotel everyday. We had to go home daily to feed our cats 2x a day but we needed baths/showers so we would have to drive all the way to Waikiki & back every day. It also meant little time or energy to cook at home so more eating out. The gas to go to and from added up too and it just felt like there was no time or money to do anything we actually wanted to do. It was really hard for Christmas too.”

Another participant described life disruptions that, among other things, translated into higher expenses:

“I had to spend so much time getting clean water, driving to and from the hotel and washing laundry at a facility with clean water that my social life was severely impacted and my ability to homeschool my children was very severely impacted. Everything took way longer and I used way more gas at a time when gas was very expensive.”

Others noted disparities in crisis response and unequal access to support: “Army families received so much more in the form of pay and benefits […]. Other [branches] had to wait for benefits that did not match those of the Army.” Civilian responses noted the particular challenge faced by those with no DoD affiliation. In the words of one survey respondent:

“My health was greatly impacted by this incident and I have yet to get any proper diagnosis, I am unable to find work because I cannot handle working anymore. I had to leave my job as a result of the health complications I have been facing. I have gotten into major debt because I was not assisted with anything because I am not active military nor veteran. This meant I had to pay for hotel lodging, hotel parking, buying food all the time because I could not cook or shower in our affected home. All of us who are civilians were left alone to suffer on our own.”

For many, the spill had lasting repercussions on their careers, as the need to relocate or seek medical care was met with professional consequences. “My job, my employees psychologically demoted me [and] my position at work. Since I was absent and late or had to leave early quite often due to the spill, I wasn’t able to run the shop as it should have been,” one person recounted. Another individual described the stigma associated with being affected: “Some leaders at work made negative comments about the people that got affected, they implied that we were exaggerating on our concerns.”

3.3.4. Social impacts

Responses to questions about impacts to social interactions and relationships were mixed with many neither agree nor disagree answers, indicating that social impacts are complex and variable. Overall, however, in both the quantitative (Fig. 8) and qualitative response (below), more negative social impacts were reported than positive. For example, 45% (n = 72) said they strongly agree or somewhat agree that they feel more isolated as a result of the fuel spill versus 25% who disagree. Likewise 48% (n = 75) strongly disagree or somewhat disagree that they feel a greater sense of belonging in their community versus 9% (n = 14) who agree (Fig. 8).

Social impacts – qualitative responses

Of those who answered the open-ended question (n=48), “If you would like to, please elaborate on how you feel the fuel spill influenced you or your family’s relationship and social connections,” the majority described negative impacts to their family relationships, community connections, and an increased sense of isolation since the spill. One shared, “We have all gotten to the point of distress. This situation caused so much stress and dysfunction within our family.” Another described how impacts on their children caused increased conflict in their marriage: “My [spouse] and I disagree about the impact of [the] fuel spill. It has caused a rift and delayed treatment of my children.” Another wrote about impacts in the context of a spouse on deployment: “The fuel spill caused a huge problem in my friendships as well as my marriage to my sponsor [military spouse] with finances and the stress of me being sick while my sponsor was on deployment.”

Others discussed that the spill had made their families feel more isolated. This was in part because of the time required to deal with unsafe water. In the words of one participant, “the fuel spill occupied all of our mental and emotional energy for months on end. Hauling water, living out of a hotel, missing the holidays, missing work… there is no way for me to quantify how that impacted my ability to interact with my friends and family.” Another participant explained, “our neighborhood was very close prior to the [fuel] spill; we had block parties regularly. With the [fuel] spill, we did not feel comfortable having similar gatherings (that involved water slides, etc.). It was harder to host people because we did not use any tap water.” Some families and marriages experienced more severe conflict. One respondent shared, “this exposure nearly caused my [spouse] and I to get a divorce in order to protect my children,” and another documenting that their “[spouse] attempted suicide, moved to [a mainland state] with family, […] and […] is pursuing divorce.”

Physical and mental health symptoms also increased feelings of social isolation as shared in one account: “I don’t like doing anything in public because of my rash. I also have severe heartburn [which] in turn makes me depressed.” Others described how the stress and trauma of the event has also made it challenging to interact with those not affected. In the words of one respondent: “It’s hard to explain the anxiety and stress it’s caused me and my family to someone who has never experienced losing a household necessity.” Another wrote, “it was very hard (and still is very hard) making friends after we moved because I’m struggling with trauma and struggling to trust people.” Others referred to “the stigma of living in impacted neighborhoods,” and that “people think we are crazy.” One respondent described social challenges as two-sided: “Many people say it’s all in our heads, others say that the military shouldn’t even be in Hawai‘i. It’s sort of catch 22, with believers mad at the military and disbelievers dismissive.”

The spill also resulted in many families leaving Hawai‘i before they normally would have, causing further disruptions to communities. During the water crisis, many families sought “compassionate reassignment” to their “home of record” or to an area that provides specialized medical care. In some cases just the family would go and the service member was required to stay here for the remainder of their “tour,” while in other cases the service member was allowed to go with the family to a new duty station. This disrupted families who had to be separated from their sponsor as well as to communities, including kids left without friends, an end to neighborhood block parties, and empty streets and homes. In the words of one participant, “many military families were forced to move off of the island to get away from the fuel spill. This caused a huge disruption to our community.” Once moved, many pointed to a difficulty in relating to new people due to the spill: “The trauma from the spill has affected all of my interpersonal relationships. It’s been incredibly hard to feel belonging in a new church community […]. Many have heard of the spill and most do not understand how traumatic it was and how much harm occurred.”

While the vast majority of social impacts reported were negative, some individuals remarked upon deepened connections. For example, one participant wrote, “if anything, my neighbors and I, along with my close friends and coworkers, looked out for each other.” Others pointed to improving community connections through volunteering during crisis response and becoming “closer to some and more distant to others.” One respondent noted, “[The] Navy was giving us no support although it is a Joint Base. We had to lean on each other and figure out how to help [Air Force] assets. We bonded together and have a stronger relationship for it.”

Finally, some pointed to challenges around work and school. Others described unsupportive work environments that did not accommodate people affected by the spill. For example, a dependent, Department of Defense healthcare employee described an unsupportive work environment that failed to accommodate people affected by the spill: “[I] was actually told by my employer that it was not that big of a deal and was told to show up to work no matter what was going on with my health as a result of the water contamination.” In the case of Navy respondents where the fuel spill was caused by their employer, there was a clear concern and fear of retribution in work settings, as stated by an active duty service member: “I will forever have on my military records the paperwork I received for speaking up in trying to protect my family.” Others discussed their kids having to miss school because of health and logistical challenges. One participant shared, “our kids were constantly sick, for months and months, missing more than half the days at the school in a month.”

3.4. Disaster response

3.4.1. Perceptions of crisis response and institutional trust

Satisfaction with institutional response to the crisis varied substantially. By far, the highest satisfaction was with the BWS, which had significantly higher levels of satisfaction (p < 0.01) than all other institutions except for the HDOH (p = 0.09) (Fig. 9). Satisfaction rates were significantly lowest with the Navy (p < 0.001), followed by the US Military (non-Navy). The CDC and EPA ranked in the middle.

Figure 9. Responses to the question: How satisfied are you with the response of the following institutions to the November 2021 fuel spill? Lowercase letter on the right vertical axis indicates compact letter display. See Supplementary Fig. 1  for responses split by respondent military affiliation.

These results mirror reported levels of confidence in various groups to act in the publics’ best interest, with the highest levels of confidence expressed in BWS, similar to confidence in scientists, medical doctors, and the HDOH (Fig. 10). The lowest confidence levels were found in the US Military and Federal Government.

Respondents also indicated that they have the least amount of trust in information from the U.S. Navy and the highest amount of trust in information from health care providers and close friends and family. The Honolulu BWS, HDOH, CDC, and EPA were the most highly trusted institutional information sources. The US Army was the most trusted military source, though the Army also was less trusted than local and state institutions and ranked similarly to social media (Fig. 11).

Survey participants were also asked whether fear of retribution in various forms affected how they responded to the crisis (respondents could select all that applied). The most frequently cited factor was fear of harassment at work (16%, n = 28) followed by fear of losing housing, and fear of losing a job for themselves or their family members (both 16%, n = 27). Fear of loss of friendships was also cited (13%, n = 22), along with fear of demotion or pass over for promotion for respondents or a family member (11%, n = 20), and fear of harassment from neighbors (9%, n = 15).

Open-ended responses (n = 72) to the question, “if you would like to, please provide any additional comments on your perception of the response to the November 20, 2021 fuel spill,” relay the aftermath of the spill. Many respondents shared that they felt ignored or “gaslit” by institutions that were supposed to protect them. One shared a sentiment held by many:

“I do not feel there has been accountability – this was a known risk that families placed in these communities by the military were not made aware of. We were lied to when the contamination occurred, told everything was fine as we smelled and tasted jet fuel. The military continues to sweep this under the rug, knowing that families are cycling out of the areas, so we are no longer in the impacted community and diminished access to recourse. While we continue to live in fear of what this means for our long term health and have residual trauma about water use and knowing what we’re drinking is clean and safe (even after relocating this has caused continued anxiety). Meanwhile, the water system remains at risk, military and Hawaiian families remain at risk.”

There was a strong sense of institutional failure and betrayal, especially by the Navy. One participant explained, “we are still coping with what happened to us. We are supposed to trust in our government and our leaders, but we were severely failed.” Many emphasized that this was particularly painful given their own identity as being part of the military institution: “Institutional betrayal is real and seeing people struggling just to be heard is hard. It is also very difficult to see the military propaganda machine working when at the same time being part of the institution.”

Some expressed a sentiment of institutional failure across the board, as expressed by one respondent: “It was mishandled on every level from top down. The communication was poor and us residents deserved better.” However, the majority of open-ended responses focused on the failure of the Navy, with many suggesting better response by the Army and the BWS. For example, one participant wrote, “the fight to get answers is so much stress. Not only are we fighting with the Navy to tell the truth of everything, we also have the stress that no other organization besides the Board of Water Supply was fighting for us and even then we question a bit.” Another shared, “I do wish the EPA, BWS, and DOH came in earlier and with more presence. I think when they did come in, they helped. However, I think a stronger presence up front would perhaps have lessened the severity of the misinformation and struggle experienced during that time.”

Others felt the response of the Army was far superior to the Navy’s response, as shared by one respondent: “[The] Army stepped up and did an amazing job of helping everyone impacted by the water crisis. The Navy dropped the ball.” Another similarly explained: “I think the Hawai‘i institutions did better than others at trying to resolve issues. The US Army also seems to have done better than other institutions at reaching out and trying to mitigate the situation.”

Many responses emphasized how more than the spill itself, It was the appearance of the Navy’s intentional cover up that had eroded their trust. As stated by one respondent: “We stopped using the tap water to drink, cook with, and give our dog. We buy bottled water now. We don’t really trust what the Navy says about the water quality. They tried to cover it up and make it seem like it wasn’t as bad as it really was.” Another shared feelings about ongoing resentment towards the Navy given how their actions made it harder for their family to respond to the crisis and its aftermath:

“I harbor so much resentment towards the DoD and how we were lied to despite obvious health issues and obviously contaminated water… Part of the harm comes from having to prove to new people that it’s true that the Navy poisoned us and lied to us despite the obvious data we had data to back up our claim… we lived for months in a house that was not safe… we spent Christmas in traffic, sobbing, because we were so overwhelmed. And still, there are people who do not know what happened and people who do not believe us.”

Others pointed to the link between feelings of betrayal and mental health outcomes: “We are extremely disappointed how the Navy responded to this crisis. The gaslighting and downplaying are so very hard on our mental health.” Another expressed, “The Navy was constantly gaslighting, manipulating and trying to scare us from sharing our testimony.” Many expressed anger at those who did not take responsibility for the situation, including one respondent who wrote: “Those Navy leaders who sat at those town halls with undrank glasses of water in front of them should all be relieved and charged with assault on all the affected people.” Finally, some expressed concern over the harm caused to Native Hawaiians and other local residents of Hawai‘i: “Hawaiians are amazing stewards of the land and it is tied to their culture. This makes me so frustrated that the Navy allowed this to happen and then covered it up for my family’s health and the Hawaiian people.”

In general, those affected by the crisis who were not active duty expressed that they did not receive the help they needed. One civilian living in Kapilina Beach Homes, a civilian neighborhood, described another layer of confusion: “Kapilina [management company, Greystar] initially told us we were not on the Navy water, although the water pipes (and all other utilities) were Navy. We learned with the BWS before Kapilina admitted that our water was contaminated.” Similarly another explained, “DoD civilians were not included in any assistance provided except when the general population was recognized as being affected.”

While the vast majority of open-ended responses expressed negative sentiments about institutional response, there were several who pointed to a positive institutional response. In the words of one respondent: “As stressful as the last 18+ months have been, I do believe that the federal, state, and local entities are working to make things right.”

3.4.2 Health care response

The majority of respondents, 65% (n = 110), received medical care, evaluation, or advice from a healthcare provider because of the fuel spill. While 24% of respondents (n = 26) rated the medical care they received for their exposure to the fuel spill as excellent or good, 40% (n = 44) rated it as neutral. Thirty-six percent (n = 40) said their medical care was bad or very bad.

Open ended question responses (n=95) to the question: “If you would like to, please elaborate on any medical care you or your family received for your exposure to the fuel spill,” revealed that people felt like their health concerns were largely ignored or intentionally not documented by health care professionals. One respondent explained, “people think we are crazy. Trying to get medical care or any medical providers to take us seriously has been an almost insurmountable challenge.” Others were treated as if they were trying to take advantage of the situation: “Illnesses brought forward during that time seemed to be judged as if we were only stating illness to get disability down the road. It very much seemed like medical staff thought we were making up how sick we felt.” Likewise, another respondent shared: “I was looked down upon as an uneducated or dramatic wife while the ‘scientists’ did their checks to see if anything was wrong. Up until there was probably fuel in the water, we were treated like idiots.”

When people were seen, there was a general sentiment that medical professionals tended to not associate their symptoms with the fuel spill due to a combination of intentional gaslighting and a lack of information and testing available regarding jet fuel and human health. For example, one survey respondent shared, “our concerns about health were diverted to everyday sicknesses and steered away from having anything to do with the fuel spill. We had symptoms for months that our doctors and emergency room doctors deemed unrelated to ingestion of the water during the spill.” One respondent, spoke to feeling gaslit in their experience with health care after the spill: “We were gaslit into believing that our symptoms couldn’t have been from the spill, but also had doctors telling us to take pictures of what they wrote down because they were fearful that the military wouldn’t put it in our records.” Another shared, “they basically told me we would just have to wait and see on the health of our baby.” One respondent felt that COVID was also used as a strategy to dismiss fuel-related health concerns: “They seem to dismiss all of our symptoms and concerns and blame everything on Covid even though we tested negative, they refuse to acknowledge our exposure and any health impacts.”

Others pointed to a lack of documentation and appropriate testing, particularly in initial visits as they were told that, “no test could show fuel in your system.” One respondent who is also a clinician explained, “as a clinician in the system, we received a letter telling us that there was nothing that could be done for those exposed. No lab tests or other tests should be ordered.” While some felt frustration toward the medical providers, others acknowledged the lack of information: “Most providers are still at a loss for how to treat symptoms or ongoing issues due to lack of advisory information and lack of overall information on what this may mean for us long term.” Others pointed to a specific avoidance of the fuel contamination: “I felt like many doctors didn’t want to ‘touch the Red Hill issue.’ Or they just went with the generic, ‘we don’t know enough about hydrocarbon exposure and hope with time it gets better.’” Another pointed specifically to military doctors as unwilling to acknowledge or document health effects related to the spill.

“No military doctor was willing to acknowledge that your condition might be related to the fuel spill. Documentation in the medical record was conveniently well worded and avoided any mention of Red Hill or Jet Fuel. I am 100% convinced that there is no correct data because it wasn’t documented. Additionally, the Red Hill Water Crisis Hotline they told everyone to call at Tripler did not document. I called for myself and two kids and there is no record of that encounter ever happening.”

In general, people expressed varying levels of care, but were particularly dissatisfied with military-affiliated doctors. A commonly reported sentiment is captured in the words of several respondents: “I feel safer with civilian unaffiliated doctors, but we don‘t always have that choice with Tricare. Military doctors downplay and gaslight us just like the military leadership did in the beginning when they guaranteed the water was safe.” Another respondent echoed this sentiment, saying there was “gaslighting from the military doctors” and that “civilian doctors in military hospitals were much better at not making me feel like I was faking everything.”

There was also frustration about not being referred to appropriate specialists in the aftermath of the event, and whether that could have helped to treat symptoms:

“Only when we were at a new mainland duty station and I switched to Tricare Select where I could choose my specialists without a referral, I was able to get to a vestibular therapist (for vertigo and balance), and occupational therapist, which has been incredibly helpful. Those options should have been available from the beginning. All the testing (blood/urine, vestibular, etc.) I had done was researched and requested by me and not suggested by my care team. Without those, I would not have improved as well. We should have never been left to our own devices to navigate such an incredibly horrifying medical incident. We are not medical experts and have lost sleep, money, and joy out of our lives because of this event that continues to rob us everyday.”

Medical assistance for those exposed to the contaminated water took different forms in the aftermath of the fuel spill. Initially, the DoD set up tents within the affected areas where people could get assistance with medical concerns. One participant recalled: “The fight to get tested for anything was near to impossible. When we went to the tent set up I feel like they barely even wrote anything down or listened.” Later, when the Red Hill Clinic opened in January 2023 perceptions were also often negative, with one person describing it as a “dog [and pony] show”.

Of the open-ended responses about health care, several noted positive health care experiences with the VA, Pali Momi ER, and specific mainland healthcare clinics/poison centers. One DoD employee shared, “As a civilian DoD [employee], not active duty, we were not offered immediate healthcare for our symptoms while living in military housing.”

3.4.3. Recommendations from those affected for future response

When asked what people would recommend to others for future crises, respondents (n = 111) emphasized both what people can do at an individual level as well as how leadership should respond. On an individual level, respondents emphasized that people should stop drinking the water immediately upon noticing any issues and should move if they are able to. They also pointed to the importance of preparation: “Prepare for a disaster. Just as you would for a hurricane or any other disaster here. Make sure you have 14 days of food and water. Have a set amount of money set aside for emergencies.”

Most of the responses, however, focused on the importance of better leadership, transparency, honesty, and communication. They emphasized the importance of first listening to those affected: “Please listen to those who are affected and believe them, do not belittle or diminish their experiences. Actually help those impacted, with adequate resources: medical, financial, mental health and a sense of community.” Respondents also provided clear advice for leadership to coordinate their communication strategy. For example, one respondent shared: “Try to communicate better, leaders show more empathy toward those affected, have a strong, effective, positive response as soon as possible, leaders listen to people.” Another pointed out that, “you can convey urgency without friction between agencies. Conflicting information creates more chaos and distrust.”

Several pointed to the Army’s response as something that could be emulated, for example,

“Do exactly what the [A]rmy did for us, but just do it faster. Showers, clean water, mental health, financial, health screeners, etc…. And most of all, speak the truth, the unknowns and only be spoken by those with the knowledge and compassion, humility goes a long way with people dealing with a crisis.”

The Army response was contrasted with the Navy response in many cases: “Don’t lie. Don’t try to cover it up. Step up like the army did and help the community through it.” Respondents emphasized honesty and a precautionary approach; in the words of one participant: “Be upfront 100% from the beginning and if there is even a slight chance an area could be affected, assume it’s affected.”

Several also pointed to the need for third party testing of water: “Have outside folks test and manage. The Navy showed that the polluter cannot be trusted to adequately respond to the messes they create.” Another also shared that they feel that people need to be notified of the water contamination before signing legally binding leases on military housing. Finally, there was a strong sentiment that this type of event needs to be prevented; in the case of Red Hill:

“The military should not have been given any extra time to defuel and remove these tanks. They covered these spills up for years and even throughout the most recent cleanup handled the process poorly and flat-out lied to the service members and their family. They should be forced to figure it out before it happens again, because it will.”

4. Discussion and Key Findings

The Red Hill fuel spill of November 20, 2021 is not an isolated incident. It is part of a longer history of military-linked environmental contamination across Hawai‘i, the Pacific, and the world (Kajihiro, 2023; Stadler et al., 2022). Although our sample size limits statistical representativeness, the findings highlight clear and ongoing harm across multiple dimensions – particularly mental health, social well-being, and financial stability – nearly two years after the initial exposure.

An important key finding is that survey respondents reported that nearly all of their household members were negatively impacted by the November 20, 2021 spill, with those under 18 being the most impacted group. Mental health impacts were most highly reported, but respondents also noted important impacts to their finances, social interactions and work and school success. Moreover, over 80% reported that all or some of these impacts were ongoing, pointing to the enduring impacts of this crisis.

Mirroring the household level impacts, the majority of respondents (68%) individually reported one or more ongoing mental or physical health symptoms, with mental health and neurological symptoms the most widely reported. These results align closely with findings from ACE 2 (CDC/ATSDR, 2022; HDOH, 2022), where 50% of respondents reported worse mental health since the spill. Notably, in our survey about 80% of respondents reported experiencing one or more new or worsening mental or physical health symptoms following the spill – a figure nearly identical to that found in the ACE 1 survey (Miko et al., 2023). This similarity suggests a comparable distribution of initial symptom reporters across the two survey cohorts.

The proportion of respondents reporting feeling depressed at least once per week (51%) was nearly double that reported in the ACE 1 study (Miko et al., 2023), suggesting increasing depressive symptoms over time. Comparison with the 2022 UHERO Rapid Health Survey Cohort also indicates higher rates of depressive symptoms and severe depression among the Red Hill–exposed population compared to an unexposed population (Juarez et al., 2022). While a definitive causal link to higher depression rates cannot be established, this finding supports broader research demonstrating mental health impacts in communities that have experienced environmental crises (Cuthbertson et al., 2016; Reuben et al., 2022).

We also found important direct financial costs, including over a third of respondents who received no reimbursement for out-of-pocket expenses and about one in five respondents who experienced direct income loss as a result of the event. These substantial economic burdens likely compound other stressors and may contribute to ongoing stress and mental health challenges. The ACE 1 study and parallel key informant interviews with businesses, community groups, and others, found similar distress among survey respondents about unreimbursed out-of-pocket expenses, and also documented serious impacts to local businesses (Parasram et al., 2024).

Many respondents also reported negative social impacts as a result of the spill, including conflicts within families and a loss of connections within communities. Much of this was related to the mental and physical health effects as well as the time and resources involved with necessary relocations and water substitutions. Open-ended responses showed feelings of social isolation were exacerbated by insufficient institutional response and poor communication, particularly by the Navy. This echoes findings from immediately after the event (Parasram et al., 2024), and also demonstrates the enduring social impacts and sentiments nearly two years later. The variation in qualitative responses, from a lack of stable connections to reports of forging new friendships, also suggest that some members of the community came together in the midst of the water crisis in support of each other.

We also found substantial variation in how satisfied respondents were with the response of various institutions. By far, respondents were most satisfied with the BWS response to the crisis and least satisfied with the Navy’s response. This result was mirrored in other questions around confidence to act in the best interest in the public and trust to provide correct information. Open-ended responses revealed deep feelings of betrayal and a loss of trust in the Navy, highlighting how inadequate responses and dismissive behaviors exacerbated mental health, social, and economic impacts. Feelings of mistrust and frustration at the lack of communication mirror those expressed in the qualitative responses of the ACE 1 and complementary key informant questionnaire (Parasram et al., 2024). Going forward, addressing the wrongs of both the spill itself and the shortcomings in the response is critical to supporting those impacted by this crisis, as well as to preparing for future crisis management.

The findings from this survey provide a critical community-based perspective, documenting the lived experiences of individuals and families navigating the  aftermath of the Red Hill crisis. The breadth and depth of reported health, financial, and emotional burdens underscore the urgent need for sustained monitoring, support, and responsive policy action. These results contribute to a broader body of evidence that can help to inform equitable disaster response.

Limitations

As with any survey-based research, this study has several important limitations. First, the relatively small sample size – 174 respondents representing approximately 592 household members – limits the statistical power of our analyses and the extent to which findings can be generalized to all households affected by the Red Hill fuel spill. Respondents were recruited from a convenience sample of individuals who had previously participated in ACE 1 and ACE 2 surveys and it is possible that those who chose to respond experienced more severe or prolonged impacts than those who did not respond. This potential selection bias could lead to an overestimation of the prevalence or intensity of certain impacts.

Second, all data were self-reported and collected approximately two years after the initial incident. As with other longitudinal surveys, reliance on self-reported measures introduces measurement limitations, including the possibility of recall bias, subjective interpretation of symptoms, and variability in how individuals assess cause and severity. While self-reporting is a valid and often necessary method in post-disaster research – especially when clinical data are not systematically collected – it does limit the ability to directly attribute health outcomes to the spill itself. In addition, there remains uncertainty about the extent and duration of exposure because environmental sampling was limited, making self-reported data one of the only viable methods of assessing health impacts (Brewer, 2023; U.S. Department of the Navy, 2022). Other factors such as the ongoing COVID-19 pandemic, personal health histories, and unrelated environmental exposures may have also contributed to the reported symptoms and outcomes (Nguyen et al., 2025).

Acknowledgements

We are deeply grateful to the JBPHH water users who gave their time to share their experiences and perspective in this survey. We thank the CDC/ATSDR and the Hawai‘i Department of Health for their assistance with survey distribution. We also thank Nathan DeMaagd and Nicole Siegal for research assistance. We are grateful to Dr. Mia Comeros, Dr. Makena Coffman, Dr. Aurora Kagawa Vivian, and Dr. Rosana Weldon for helpful reviews of the manuscript. This work was funded by State of Hawai’i Department of Health (Grant #44406) and the United States Geological Survey Water Resources Research Center and the United States Geological Survey Water Resources Research Institutes Program (WRRIP, Grant #G21AP10625-03).

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Appendix

Supplementary Table 1
Research questions and related survey questions. Note: the questions below do not represent all that were asked in the survey.

Question	Format (number of responses)
Objective 1: Document the perceived social, economic, mental, and physical health impacts of the November 2021 Red Hill fuel spill nearly two years after the event
Please rate the following in terms of how impacted you feel you and your household were by the November 2021 fuel spill. – Household’s physical health, mental health, educational or work success, finances, social interactions, recreation and leisure	Four-point scale (from Very Impacted to Not Impacted). (n = 171)
Please indicate whether you have experienced any of the following symptoms since November 20, 2021.	Indicated if new or worsening since fuel spill, persisted >30 days, and if symptoms continue. (n = 155)
If you would like to, please elaborate on how you feel the fuel spill influenced you or your family’s relationships and social connections.	Open-ended. (n = 48)
If you would like to, please elaborate on any medical care you or your family received for your exposure to the fuel spill.	Open-ended. (n = 95)
If you would like to, please elaborate on any health issues you or your family experienced since the fuel spill.	Open-ended. (n = 51)
If you would like, please share the ways that you and your family have responded or coped in the face of this event.	Open-ended. (n = 59)
If you would like to, please share anything else you would like us to know about your and your family’s experience related to the Red Hill fuel spill and water contamination.	Open-ended. (n = 61)
Please describe any discrimination or bias faced as a result of your experience with the water contamination.	Open-ended. (n = 39)
Objective 2: Understand perceptions of the crisis response and resultant levels of confidence in various public institutions
How satisfied were you with the response of the following institutions to the November 2021 Red Hill fuel spill? – EPA, CDC, U.S. Navy, U.S. Military (not Navy), State of Hawai‘i Department of Health, Honolulu Board of Water Supply	Five-point scale (from Very Dissatisfied to Very Satisfied). (n = 171)
How much do you trust each of these sources to provide correct information? -Your doctor or health care provider, your faith leader, your close friends and members of your family, people you go to work or class with or other people you know, etc.	Five-point scale (from “Not at all” to “A great deal”; “Don’t know”). (n = 172)
Please select your confidence in the following to act in the best interests of the public: – Medical doctors, scientists, journalists and the news media, religious leaders, the military, the CDC, the EPA, Hawai‘i Department of Health, Federal Government	Four-point scale (from “Great deal” to “No confidence at all”). (n = 171)
Overall, how would you rate the medical care you received for your exposure to the fuel spill?	5-point scale (from “Very good” to “very bad”). (n = 110)
If you would like to, please elaborate on any medical care you or your family received for your exposure to the spill.	Open-ended. (n = 95)
If you would like, please share the ways that you and your family have responded or coped in the face of this event.	Open-ended. (n = 59)
If an event like this occurred in a different community, what would recommend to residents, first responders, and community leaders?	Open-ended. (n = 111)
If you would like to, please provide any additional comments on your perceptions of the response to the November 20, 2021 Red Hill fuel spill.	Open-ended. (n = 72)

Supplementary Table 2
Self-reported physical and mental health symptoms. Responses to the prompt: “Please indicate whether you have experienced any of the following symptoms since November 20, 2021.” Respondents were asked whether they had had a “new or worsening symptom since November 2021”, whether the “symptoms had persisted for 30 days or more”, and whether they were “still experiencing” these symptoms at the time of the survey. Responses are number of respondents and percent of respondents. The list of symptoms was based on Miko et al. (2023) and Brewer (2023).

		New or Worsening	New since 2021	Worse since 2021	30+ days	Still experiencing
CARDIO-VASCULAR		66 (38%)	52 (30%)	42 (24%)	16 (9%)	39 (22%)
Anemia		19 (11%)	9 (5%)	10 (6%)	3 (2%)	17 (10%)
Bloody nose		16 (9%)	10 (6%)	6 (3%)	1 (1%)	10 (6%)
Blue lips or fingertips		8 (5%)	8 (5%)	0 (0%)	0 (0%)	3 (2%)
Breathlessness		36 (21%)	21 (12%)	15 (9%)	4 (2%)	15 (9%)
Burning sensation in chest		17 (10%)	11 (6%)	7 (4%)	6 (3%)	8 (5%)
Chest tightness or pain / angina		33 (19%)	25 (14%)	9 (5%)	4 (2%)	15 (9%)
Elevated heart rate		31 (18%)	21 (12%)	10 (6%)	3 (2%)	13 (7%)
High blood pressure		29 (17%)	14 (8%)	15 (9%)	1 (1%)	19 (11%)
Irregular heartbeat / Arrhythmia		22 (13%)	14 (8%)	8 (5%)	2 (1%)	14 (8%)
Slowed heart rate		3 (2%)	1 (1%)	2 (1%)	0 (0%)	2 (1%)
Swollen limbs / Fluid retention in limbs		15 (9%)	11 (6%)	5 (3%)	4 (2%)	11 (6%)
DENTAL / ORAL HEALTH		43 (25%)	31 (18%)	18 (10%)	7 (4%)	33 (19%)
Bleeding gums		20 (11%)	11 (6%)	9 (5%)	1 (1%)	10 (6%)
Blistered lips / gums		17 (10%)	13 (7%)	4 (2%)	2 (1%)	9 (5%)
Burns inside the mouth		8 (5%)	8 (5%)	1 (1%)	2 (1%)	6 (3%)
Chronic dry / chapped lips		22 (13%)	16 (9%)	6 (3%)	0 (0%)	21 (12%)
Dry mouth		15 (9%)	9 (5%)	6 (3%)	3 (2%)	20 (11%)
Increased number of cavities after the fuel spill		16 (9%)	10 (6%)	6 (3%)	1 (1%)	13 (7%)
Increased tooth sensitivity		23 (13%)	17 (10%)	6 (3%)	1 (1%)	28 (16%)
GASTROINTESTINAL		81 (47%)	64 (37%)	39 (22%)	24 (14%)	63 (36%)
Bloody stool		15 (9%)	12 (7%)	4 (2%)	4 (2%)	8 (5%)
Burning sensation (general)		37 (21%)	30 (17%)	8 (5%)	10 (6%)	19 (11%)
Constipation		27 (16%)	15 (9%)	13 (7%)	5 (3%)	18 (10%)
Diarrhea		53 (30%)	36 (21%)	20 (11%)	12 (7%)	25 (14%)
Distention of the stomach		21 (12%)	16 (9%)	6 (3%)	6 (3%)	16 (9%)
Excessive gas		28 (16%)	22 (13%)	7 (4%)	5 (3%)	25 (14%)
Heartburn		36 (21%)	18 (10%)	19 (11%)	8 (5%)	32 (18%)
Nausea		47 (27%)	30 (17%)	19 (11%)	10 (6%)	29 (17%)
Stomach cramps		41 (24%)	28 (16%)	15 (9%)	9 (5%)	28 (16%)
Vomiting		28 (16%)	24 (14%)	7 (4%)	6 (3%)	5 (3%)
MENTAL HEALTH		94 (54%)	67 (39%)	57 (33%)	33 (19%)	86 (49%)
Anxiety		87 (50%)	41 (24%)	49 (28%)	22 (13%)	80 (46%)
Agitation/irritability		66 (38%)	34 (20%)	33 (19%)	20 (11%)	51 (29%)
Difficulty sleeping		69 (40%)	31 (18%)	40 (23%)	19 (11%)	65 (37%)
Euphoria		2 (1%)	2 (1%)	1 (1%)	1 (1%)	1 (1%)
Feeling depressed		55 (32%)	30 (17%)	27 (16%)	13 (7%)	50 (29%)
Paranoia		32 (18%)	24 (14%)	10 (6%)	6 (3%)	30 (17%)
Poor judgment		14 (8%)	8 (5%)	8 (5%)	4 (2%)	13 (7%)
Restlessness / Agitation		45 (26%)	26 (15%)	21 (12%)	11 (6%)	45 (26%)
Sudden / intense mood swings		36 (21%)	22 (13%)	15 (9%)	8 (5%)	37 (21%)
Tension/nervousness		68 (39%)	44 (25%)	28 (16%)	18 (10%)	64 (37%)
NEUROLOGICAL		80 (46%)	64 (37%)	46 (26%)	31 (18%)	77 (44%)
Confusion / brain fog		67 (39%)	49 (28%)	19 (11%)	16 (9%)	55 (32%)
Difficulty concentrating		59 (34%)	46 (26%)	16 (9%)	14 (8%)	51 (29%)
Difficulty remembering things		60 (34%)	44 (25%)	17 (10%)	14 (8%)	55 (32%)
Disorientation		19 (11%)	16 (9%)	3 (2%)	4 (2%)	14 (8%)
Dizziness		52 (30%)	37 (21%)	16 (9%)	9 (5%)	38 (22%)
Drowsiness		41 (24%)	28 (16%)	15 (9%)	11 (6%)	32 (18%)
Feeling unusually sleepy or fatigued		59 (34%)	42 (24%)	19 (11%)	17 (10%)	53 (30%)
Headache		60 (34%)	38 (22%)	25 (14%)	13 (7%)	55 (32%)
Loss of consciousness / fainting		6 (3%)	2 (1%)	4 (2%)	2 (1%)	4 (2%)
Migraine		40 (23%)	20 (11%)	24 (14%)	17 (10%)	41 (24%)
Muscle tremors		21 (12%)	14 (8%)	8 (5%)	4 (2%)	18 (10%)
Seizures / convulsions		3 (2%)	3 (2%)	0 (0%)	2 (1%)	3 (2%)
Slurred speech / stuttering		7 (4%)	6 (3%)	1 (1%)	2 (1%)	10 (6%)
RESPIRATORY		46 (26%)	39 (22%)	17 (10%)	16 (9%)	31 (18%)
Bloody nose		12 (7%)	11 (6%)	1 (1%)	3 (2%)	5 (3%)
Burning nose or throat		23 (13%)	21 (12%)	4 (2%)	5 (3%)	9 (5%)
Burning of lungs		13 (7%)	11 (6%)	3 (2%)	2 (1%)	3 (2%)
Coughing		32 (18%)	22 (13%)	11 (6%)	7 (4%)	14 (8%)
Difficulty breathing / feeling out of breath		31 (18%)	22 (13%)	10 (6%)	8 (5%)	18 (10%)
Fluid in the lungs		2 (1%)	2 (1%)	0 (0%)	1 (1%)	0 (0%)
Runny nose		24 (14%)	14 (8%)	10 (6%)	8 (5%)	16 (9%)
Wheezing in chest		17 (10%)	10 (6%)	7 (4%)	5 (3%)	7 (4%)
SKIN & EYE SYMPTOMS		76 (44%)	61 (35%)	38 (22%)	28 (16%)	60 (34%)
SKIN	Burns appear on skin	23 (13%)	20 (11%)	4 (2%)	7 (4%)	8 (5%)
	Dry or itchy skin	64 (37%)	47 (27%)	21 (12%)	14 (8%)	43 (25%)
	Red patches on skin	39 (22%)	32 (18%)	11 (6%)	11 (6%)	22 (13%)
	Skin blisters	10 (6%)	9 (5%)	2 (1%)	2 (1%)	4 (2%)
	Skin pain	20 (11%)	18 (10%)	6 (3%)	4 (2%)	16 (9%)
	Skin rash	53 (30%)	40 (23%)	20 (11%)	14 (8%)	33 (19%)
	Sweating	17 (10%)	8 (5%)	9 (5%)	3 (2%)	14 (8%)
EYE	Corneal damage	1 (1%)	1 (1%)	1 (1%)	1 (1%)	2 (1%)
	Double vision	15 (9%)	13 (7%)	2 (1%)	3 (2%)	11 (6%)
	Increased watery eyes	24 (14%)	18 (10%)	7 (4%)	4 (2%)	18 (10%)
	Irritation / pain / burning of eyes	41 (24%)	34 (20%)	9 (5%)	6 (3%)	31 (18%)
	Redness	31 (18%)	23 (13%)	9 (5%)	6 (3%)	14 (8%)
URINARY TRACT		18 (10%)	14 (8%)	8 (5%)	3 (2%)	8 (5%)
Bladder infection		10 (6%)	6 (3%)	5 (3%)	2 (1%)	4 (2%)
Blood in urine		10 (6%)	9 (5%)	1 (1%)	2 (1%)	1 (1%)
Dark colored urine		7 (4%)	7 (4%)	0 (0%)	1 (1%)	3 (2%)
Pain with urinating		9 (5%)	5 (3%)	4 (2%)	2 (1%)	4 (2%)

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^[1] The figure of 93,000 is a conservative estimate of potentially exposed individuals released by the U.S. Navy Region Hawai‘i in the early days after the November 20, 2021 fuel spill. It reflects internal Navy estimates from that time and has not been independently verified, but was derived by considering regular fluctuations of base personnel, including Navy tenants, non-Navy tenants, family housing, barracks, ships, submarines, squadrons, recreational and family support facilities, and commercial entities served by the water system. This was confirmed through personal correspondence with the U.S. Navy Region Hawai‘i on April 21, 2025.