Puerto Rico: How Do We Know 3,000 People Died as a Result of Hurricane Maria?

Outside the emergency room at Centro Medico in San Juan, P.R., after Hurricane Maria. Death tolls from the storm have varied widely.

Updated Sept. 13, 2018.

When Hurricane Maria struck Puerto Rico a year ago, it was clear that the storm had left a fatal imprint on the island — and that the magnitude might take months to fully assess.

That has proved to be the case. While the government in the early weeks reported that 64 people had died in the storm, a number of assessments in the ensuing months have demonstrated that the toll was much higher.

Recently, the Puerto Rican government revised its official death estimate to 2,975, reflecting the fatalities that occurred during Hurricane Irma and Maria, as well as after — deaths that were because of the storms’ brutal and lingering impact.

This week, President Trump raised new questions about the death toll. He said on Twitter that “3000 people did not die in the two hurricanes that hit Puerto Rico.” It was only later, well after the storms, he said, that the numbers started to go up.

“This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico,” Mr. Trump said “If a person died for any reason, like old age, just add them onto the list. Bad politics.”

[Read: Rejecting Puerto Rican Death Toll, Trump Accuses Democrats of Inflating It]

Was it bad science?

Experts who study the health impacts of natural disasters say no.

Shortly after the storm in September 2017, the official death toll stood at 64. That number included only people whose death certificates listed Hurricane Maria as a contributor, as certified by the Puerto Rico Forensic Sciences Institute in San Juan.

But under pressure from a skeptical public, the Puerto Rican government announced in December that all deaths that had occurred in the months after Hurricane Maria would be reviewed, and that people who had died either directly or indirectly as a result of the storm would be included in a revised tally.

The authorities commissioned researchers at George Washington University’s Milken Institute of Public Health to do this work, which has not yet been completed. However, the researchers came back with an initial report in August, which compared the total number of deaths that occurred in the months after the hurricanes with the number that would normally have been expected.

This provided the scientific foundation upon which the territorial government immediately announced that it was revising its death toll estimate upward, to match the numbers in the new report.

The federal government says yes. In relation to hurricane deaths, the term “direct” means those that occurred from drowning or other effects of the storm itself. “Indirect” deaths include those in which related factors, such as difficulty reaching a hospital for care, or trouble refilling medical prescriptions, played a role.

George Washington researchers said they found that doctors in Puerto Rico at the time of the storm were not aware of new guidelines from the federal Centers for Disease Control and Prevention, released the month after the hurricane, which recommend that doctors also consider a natural disaster’s indirect impacts in assessing how to tally deaths.

In December, The New York Times analyzed vital statistics from the Puerto Rican government. They showed that in the 42 days after Hurricane Maria made landfall on Sept. 20, 2017, 1,052 more people than usual died in Puerto Rico.

That figure was particularly striking because thousands of people had left the island, including many with chronic medical conditions. Based on the likelihood that the population there was smaller in the fall of 2017, we would have expected the number of deaths per day to decrease, not increase.

To obtain our figure of 1,052, we compared the number of deaths for each day in 2017 with the average of the number of deaths for the same days in 2015 and 2016. The figures came from the Puerto Rican government, which provided us with tables showing the number of deaths per day and deaths broken down by cause. The 2017 numbers were preliminary, so we limited our analysis to September and October.

On June 8, the health department released updated figures to The Times, which showed an even more pronounced trend toward increased deaths in certain categories, lasting into at least October as utility failures persisted. The figures for September 2017 exceed those provided at the time of the Times study, and the department had provided only preliminary data for October until June.

In September and October of 2017, 197 people died of sepsis — a complication of severe infection. That was a 55 percent increase from the average for the same months in 2015 and 2016. Those changes could be explained by delayed medical treatment or poor conditions in homes and hospitals.

The number of diabetes deaths in September and October 2017, at 666, was 46 percent higher than the average for the same period in the two previous years. Many people with diabetes had difficulty keeping insulin refrigerated, and some had trouble maintaining special diets.

Deaths from chronic respiratory diseases and Alzheimer’s also appeared to be increased. As for suicide deaths, 49 people took their lives in September and October of 2017, whereas in the same months of 2015 and 2016, an average of 33 people died by suicide.

A study published in The New England Journal of Medicine, one of the most highly regarded peer-reviewed medical journals, analyzed a longer period than we did. It also used completely different methods.

Researchers visited more than 3,000 residences across the island and interviewed their occupants, asking whether anyone in their households had died, and whether the storm and its aftermath might have contributed. Residents reported that 38 people living in their households had died between Sept. 20, 2017, when Hurricane Maria struck, and the end of that year.

That toll, converted into a mortality rate, was extrapolated to the larger population and compared with official statistics from the same period in 2016. Researchers arrived at an estimate of roughly 4,600.

At the time, it was probably a good estimate — although the fine print was important. Because the number of households surveyed was relatively small in comparison to the population’s size, there was a large margin of error. The true number of deaths beyond what was expected could range from nearly 800 to close to 8,500 people, the researchers’ calculations showed. The widely reported figure of 4,645 was simply the midpoint of that statistical window, known as a 95 percent confidence interval. Including a midpoint figure in such a report is standard academic practice.

The study’s main finding was that residents of Puerto Rico died at a significantly higher rate during the three months after the hurricane than they did during the same period in the previous year, and that roughly a third of those deaths resulted from delayed medical care. The researchers said in the report that their conclusions were consistent with the analyses of The Times and others.

For one thing, this was the study that the government had commissioned itself — the one it said would answer any remaining questions.

It would have been difficult for territorial leaders to ignore the findings. But there were several factors that gave it significant credibility.

Researchers looked at deaths for a longer time period, from September when Irma and Maria hit until this past February. Deaths, they found, continued to be elevated throughout this period.

The researchers also adjusted their calculations for what they estimated to be an 8 percent drop in the population after the storm and prolonged power failures, when thousands of people fled for the mainland. That exodus made it even more significant that deaths had increased compared with previous years.

All told, they found, there was a total “excess mortality” of 2,975 in the months after the storm that could reasonably be attributable to Maria’s effects.

This was not people dying of “old age,” as Mr. Trump put it. Average life expectancies tend to be relatively constant. This was a spike in mortality that was almost certainly because of the prolonged impacts — lack of access to health care, infections, long-term injuries — of the storm and its aftermath.

No. George Washington researchers hope to continue their work over the course of the next year to examine individual death certificates and conduct detailed, in-person interviews to continue refining their findings.

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