More than 4,600 people are believed to have died in Puerto Rico from the catastrophic Hurricane Maria according to a new study – far in excess of the official government death toll which stands at 64.
The latest estimate of the number of dead from Harvard’s public health school says that many of the deaths were likely from delayed medical care. The island US territory was largely without electricity and access to basic services for several months after the 2017 hurricane season.
The study, published in the New England Journal of Medicine, called the official death toll of 64 “a substantial underestimate”. The researchers concluded that there were 4,665 “excess deaths” – meaning those people would not likely have died had Puerto Rico not been in such a disastrous state due to the hurricane – between 20 September and 31 December 2017.
Maria, a major hurricane with winds close to 150 miles (241 km) per hour, caused an estimated $90bn in damage to an island already struggling economically, and many residents have subsequently left.
The study noted that its figure is not precise, and that more definite studies are still to be released. But the new estimate, reached using methods that have not previously been applied to the disaster, comes amid widespread concerns that the official death toll was not accurate.
Researchers estimated a 95 per cent likelihood the death toll was in the range of between 800 and 8,500 people. They say about 5,000 is a “likely figure”.
The study did not just count bodies for the death toll. Researchers surveyed nearly 3,300 random households on the island and took into account each of their experiences over a three week period in January 2018.
Respondents were not paid and were asked if a household member had died directly or indirectly as a result of the storm. Missing people were not counted as deaths. Respondents were also asked about deaths within a five minute walking distance of their homes.
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The people in those households reported 38 deaths, which was then extrapolated across Puerto Rico’s population of 3.4 million.
Researchers calculated that the island’s mortality rate jumped a whopping 62 per cent in the months following the hurricane.
The official government death toll has long been a matter of controversy, particularly following what critics labelled a slow response to the disaster by the US federal government and President Donald Trump.
The tally of 4,645 dead is more than four times higher than a December estimate by The New York Times, which said the actual death toll was probably about 1,052. A Pennsylvania State University study put the number at 1,085.
The official count is based on how many deaths the medical examiner attributed directly to the category four hurricane, but the study argues that the impact of the aftermath – including the lack of electricity, closed roads due to fallen trees and damaged infrastructure – should be taken into account. There is also the issue that many residents faced in getting access to basic food, water and medical supplies.
“Hurricane Maria caused massive infrastructural damage to Puerto Rico... In our survey, interruption of medical care was the primary cause of sustained high mortality rates in the months following the hurricane,” the study noted. The survey also found that approximately one-third of the total deaths in the months following Maria were caused by delayed or interrupted health care.
Caroline Buckee, a lead author of the new study and epidemiologist at Harvard, told NPR: “Our approach... provides a different kind of estimate and a different kind of insight into the impact of the hurricane.” She added that the government could take on the same methods to do an even larger survey and get more accurate results.
Researchers said that one of the reasons the number of those killed given in the study is an estimate is because deaths may have continued well into 2018. However, getting closer to a likely death toll is important in that it may help dictate future disaster relief operations, and affect disaster funding and aid infrastructure planning in the recovery process. It also helps survivors with closure.
The researchers said that in the aftermath of Maria households went, on average, 68 days without water, 84 days without electricity and 41 days without mobile phone coverage. In the most remote areas, 83 per cent of households were still without power by 31 December.
The government of Puerto Rico has also commissioned a similar study from George Washington University’s school of public health, and the results are due later this year.
Puerto Rico’s government released a statement on Tuesday welcoming the study and saying it would analyse it further.
“As the world knows, the magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities. We have always expected the number to be higher than what was previously reported,” Carlos Mercader, executive director of the Puerto Rico Federal Affairs Administration said in the government statement.
Image copyright AFP/Getty Image caption The official death toll stands at 64
Hurricane Maria killed more than 4,600 people in Puerto Rico, 70 times the official toll, according to estimates in a Harvard University study.
A third of deaths after September's hurricane were due to interruptions in medical care caused by power cuts and broken road links, researchers say.
The Puerto Rico government said it "always expected the number to be higher than what was previously reported".
The official death toll stands at 64.
But experts say an accurate count was complicated by the widespread devastation wreaked by the storm.
Carlos Mercader from Puerto Rico's Federal Affairs Administration said he welcomed the Harvard survey.
"The magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities," he said.
He added that the island's authorities had also commissioned George Washington University to study the number of deaths and these findings would be released soon.
"Both studies will help us better prepare for future natural disasters and prevent lives from being lost," he said.
The Harvard researchers said interviews conducted in Puerto Rico suggested a 60% increase in mortality in the three months after the storm.
They contacted more than 3,000 randomly selected households between January and March this year and asked about displacement, infrastructure loss and causes of death.
Were deaths preventable?
Aleem Maqbool, BBC News, Washington
Many Puerto Ricans we spoke to felt their immense suffering after the hurricane had been trivialised and that the emergency response has been lacklustre.
A relatively small number of people may have been killed by the physical impact of the storm, but six months later we met people who had lost relatives as a result of interrupted medical care and saw others struggling to pay for expensive generators on which they were running vital life support equipment.
There was also reported to have been a spike in the number of suicides. We found many still without homes and thousands who had been living without electricity since the day Hurricane Maria struck.
Whatever the true number of those killed as a result of the storm, it is now certain to be many times the official figure. The question for US authorities about Puerto Rico, an American territory, is how many of those deaths could have been prevented with a better emergency response?
They then compared their results with the official mortality rates for the same period in 2016, more than a year before the hurricane struck the island.
The researchers said that interrupted medical care was the "primary cause of sustained high mortality rates in the months after the hurricane".
Media playback is unsupported on your device Media caption Six months after hurricanes, many on this US island still suffer in the dark
Disruption to health care was a "growing contributor to both morbidity and mortality" in natural disasters, they said, because growing numbers of patients had chronic diseases and used sophisticated equipment that relied on electricity.
On Twitter, several users noted that the death toll exceeds the nearly 3,000 Americans that were killed during the 9/11 attacks.
Skip Twitter post by @MrGordian Whole wars have taken less lives than Hurricane Maria. The American government could not care less. — Graybones (@MrGordian) May 29, 2018 Report
The mayor of San Juan, the largest city in Puerto Rico, tweeted that "the negligence that contributed to [the deaths] cannot be forgotten.
Carmen Yulin Cruz added that the death toll is "a violation of our human rights".
Skip Twitter post by @CarmenYulinCruz These deaths & the negligence that contributed to them cannot be forgotten. This was, & continues to be, a violation of our human rights. — Carmen Yulín Cruz (@CarmenYulinCruz) May 29, 2018 Report
Hurricane Maria caused the largest blackout in US history, according to research consultancy the Rhodium Group.
There have also been repeated power cuts since then, including an island-wide one in April, nearly seven months after the hurricane.
Overall, Hurricane Maria caused losses of $90bn (£68bn), the US National Oceanic and Atmospheric Administration (Noaa) said.
The Caribbean island is home to 3.4 million US citizens.
Estimate of 4,600 deaths in sharp conflict with official toll of 64, and researchers say new evaluation may be an underestimate, too
The landfall of Hurricane Maria in Puerto Rico last September led to the death of thousands on the island, according to a new study – in sharp conflict with the official government death toll of 64.
The report in the New England Journal of Medicine concludes that as many as 4,600 “excess deaths” occurred in the aftermath of the storm due to failures of medical and other critical infrastructure, and described the official number as “a substantial underestimate”.
Researchers said their fresh evaluation was probably an underestimate, too, owing to problems with communications that persist in the storm’s aftermath. In an enormous range of calculations, they said there is a 95% likelihood the death toll was somewhere between approximately 800 and 8,500 people.
Carmen Yulín Cruz, six months after Hurricane Maria: 'I did what had to be done' Read more
Hurricane Maria, which peaked as a category 5 hurricane just before reaching Puerto Rico, brought devastating winds and catastrophic flooding to the Spanish speaking US territory. In the days, weeks and months that followed, roads and electrical lines were slow to be restored, grinding much of life to a near halt. There were also severe shortages of food and lack of access to potable water in many areas. Governor Ricardo Roselló called the storm “the biggest catastrophe in modern history” for the the island.
Despite that cataclysmic account from authorities, the official death toll from the storm has remained at just 64. Largely the discrepancy between the two figures has to do with methodology. The government figure accounts for those whose deaths were confirmed by the Institute of Forensic Sciences as directly disaster-related. The new study used baseline mortality figures to calculate “excess deaths”, or loss of life that otherwise would not have occurred if the island hadn’t been plunged into a prolonged humanitarian disaster. Researchers used random household surveys to ask residents about their experiences during the storm and in its aftermath.
The report follows a similar finding from the Center for Investigative Journalism in December which found that the actual death toll on the island in the wake of the storm exceeded 1,000 people. That report found that due to the severing of critical infrastructure, hundreds of vulnerable people died in hospitals and nursing homes from conditions such as diabetes, Alzheimer’s, kidney disease, hypertension, pneumonia and other respiratory diseases.
San Juan, Puerto Rico (CNN) An estimated 4,645 people died in Hurricane Maria and its aftermath in Puerto Rico, according to an academic report published Tuesday in a prestigious medical journal. That figure dwarfs Puerto Rico's official death toll of 64, which the article's authors called a "substantial underestimate" of Hurricane Maria's death toll.
"These numbers ... underscore the inattention of the US government to the frail infrastructure of Puerto Rico," authors from Harvard University and other institutions wrote in the New England Journal of Medicine.
The official death toll in Puerto Rico has been the subject of substantial controversy since Hurricane Maria hit this island, a US territory, on September 20. CNN and other news outlets have used government statistics and extensive interviews with families of the deceased and funeral home directors to question the Puerto Rican government's official tally of deaths.
Previous estimates suggested Maria contributed to about 1,000 deaths.
The team from Harvard arrived at its much-higher estimate by surveying 3,299 randomly chosen households across the island earlier this year. Authors compared results of that survey -- which asked island residents about deaths in their homes, among other things -- with official mortality statistics from 2016. That allowed researchers to estimate the number of deaths that likely occurred as a result of Hurricane Maria between the date of the storm and December 31, 2017.
"The difference is that we went out and we had boots on the ground and we did the interviews," said Domingo Marqués, an associate professor of clinical psychology at Carlos Albizu University in Puerto Rico, who was among the report's authors.
"Statistically, it's like having interviewed the whole island," he said.
Still, the exact death toll is likely to remain a mystery. Experts tell CNN it is difficult to say with certainty whether a hurricane "caused" certain deaths, especially those that occurred because of the chaotic and unsafe conditions that have lingered for months in Puerto Rico. Marqués and colleagues say 793 to 8,498 hurricane deaths occurred.
In a news conference on Tuesday, Hector Pesquera, head of Puerto Rico's public safety department, said the government did not have reason to question the latest estimates, which come from researchers at Harvard University as well as Beth Israel Deaconess Medical Center, the University of Colorado and universities in Puerto Rico.
US territory officials stressed that the Puerto Rican government has hired George Washington University to conduct an assessment of Maria's death toll and that the results of that review are still forthcoming. Previously, officials had expected the George Washington University report to be released this spring, before the Atlantic hurricane season, which begins on June 1.
"The Government of Puerto Rico welcomes the newly released Harvard University survey and we look forward to analyzing it," Carlos R. Mercader, executive director of the Puerto Rico Federal Affairs Administration, said in a press release.
"As the world knows, the magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities. We have always expected the number to be higher than what was previously reported. That is why we commissioned The George Washington University to carry out a thorough study on the number of fatalities caused by Hurricane Maria which will be released soon. Both studies will help us better prepare for future natural disasters and prevent lives from being lost."
The Harvard study says the Puerto Rican and US governments did not provide adequate services -- including electrical power and medical assistance -- after the hurricane. It also notes that Puerto Rican officials have refused to make public basic mortality statistics.
The US Federal Emergency Management Agency (FEMA), which oversees disaster recovery, has said it encountered unique logistical challenges on the island after the storm that make comparisons between the response to Maria and other storms problematic.
CNN and the Center for Investigative Journalism (CPI) in Puerto Rico are suing the island's demographic registry for access to death records that have been withheld.
In November, CNN surveyed 112 funeral homes -- about half the total -- across Puerto Rico, in a moment when many communication systems remained inoperable. At that time, funeral home directors identified 499 deaths they considered to be hurricane-related.
Puerto Rico added at least two people to its official count following CNN's investigation.
Grave of Natalio "Pepito" Rodríguez Lebrón at the Municipal Cemetery of Maunabo in Puerto Rico. His family says they couldn't afford to power a breathing machine that helped keep him alive. Rodriguez died January 6 from a pulmonary disease.
One was Quintín Vidal Rolón, 89, who died in a lantern fire that relatives said occurred because of the storm; Vidal was using the lantern because he didn't have electricity.
Other uncounted deaths occurred in environments where people lacked electricity or other basic services, including communications. Many roads were blocked after the storm. And hurricane-related deaths appear to have continued for months after the September hurricane.
Natalio Rodriguez Lebron, 77, for example, died in Maunabo, Puerto Rico, in January. His family says that's because they couldn't afford to power a breathing machine that helped keep him alive.
While most power and water service has been restored, thousands of people here remain without electricity -- more than eight months after Hurricane Maria.
The latest death-toll estimate could be seen as an indictment of the federal response to the storm, said Dr. Gregory J. Davis, director of the University of Kentucky's Forensic Pathology Consultation Service.
"This alone should make your readers and the readers of the New England Journal really stand up and take notice -- and frankly be asking our government 'Why?' " he said. "Our government is not doing what they should be doing down there. It's infuriating, that's the bottom line."
The New England Journal of Medicine article adds to "a growing consensus that deaths have been undercounted by the Puerto Rican government," said Alexis Santos, a demographer at Penn State University who also has researched the death toll following Maria.
"This is a valid way of looking at it," he said of the research from Harvard. Still, "The way this is done, by interviews with people in different barrios in Puerto Rico, it seems to me that someone could report a death as associated with the hurricane when it was not."
That could result in an overcounting of deaths, he said.
The Harvard team, meanwhile, says that, if anything, its estimates are low. It would be impossible to identify some deaths using a survey, Marqués said. For example, if a person died while living alone there would be no person in that home able to answer questions.
Researchers also underscored how much an accurate death toll matters -- in terms of supplying adequate assistance, for the families of victims and for the prevention of future deaths.
"As the United States prepares for its next hurricane season," the researchers wrote, "it will be critical to review how disaster-related deaths will be counted, in order to mobilize an appropriate response operation and account for the fate of those affected."
