Island’s storm-linked toll tops 4,600, study asserts

SAN JUAN, Puerto Rico — A new study contends that about 4,600 deaths — rather than the official toll of 64 — occurred in Puerto Rico in the three months after Hurricane Maria devastated the island, mostly because of problems getting medicines or medical care.

Researchers from Harvard T.H. Chan School of Public Health and other institutions surveyed a small sample of neighborhoods and from that tallied up to 4,600 more deaths than the same period last year, far more than earlier studies have suggested. At least one independent expert questioned the methods and the number in the new study.

“This estimate could be off by thousands. Easily,” Donald Berry, a professor of biostatistics at the University of Texas MD Anderson Cancer Center, said in an email.

The research was published online in the New England Journal of Medicine. It’s the latest study to analyze how many people died during or after the Category 4 storm that hit the U.S. territory in September, causing more than an estimated $100 billion in damage. The researchers led by Harvard University called the official toll of 64 deaths a “substantial underestimate.”

Maria caused the longest blackout in U.S. history, leaving the island of 3.3 million people without power, including hospitals and nursing homes where patients relied on respirators. Researchers surveyed 3,299 households earlier this year and used the findings to extrapolate to the whole island. They found that 31 percent reported disruptions in medical services, and more than 14 percent said they were unable to access medications.

“Indirect deaths resulting from worsening of chronic conditions or from delayed medical treatments may not be captured on death certificates,” researchers said in the study.

They calculated 4,645 more people died in the three months after Maria compared with the same period in 2016. One of the researchers, Rafael Irizarry of Harvard University, said the estimate is uncertain because of its limited size but that the study still provides valuable information, including how some people died.

Previous studies have found that the number of direct and indirect hurricane-related deaths in Puerto Rico is higher than the official toll, including a 2017 report that there were nearly 500 more deaths than usual on the island in September.

In late February, Puerto Rico’s governor announced that a team of experts at George Washington University would lead an independent review to determine the number of deaths caused by Hurricane Maria in ongoing accusations that the government undercounted the toll. A preliminary report was due in May, but Puerto Rico officials announced last week that the team requested and was granted more time. The director of that study did not return messages for comment.

The government of Puerto Rico issued a statement Tuesday in response to the study saying that it welcomed the research and would analyze it.

“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,” said Carlos Mercader, executive director of Puerto Rico’s Federal Affairs Administration.

Meanwhile, a couple of media organizations have gone to court to obtain more details on the deaths reported in Puerto Rico last year. Demographers have said Puerto Rico recorded an official average of 82 deaths a day in the two weeks before Maria hit. The number increased to 117 a day after the storm pummeled the island in mid-September and then fell below usual in October.

The new study’s results were produced quickly and at a modest cost by focusing on a randomized sample of the population, and by using mobile mapping technology and an army of graduate students to conduct the survey.

“It helped that a lot of them were psychology students, because they were going to be dealing with families in distress,” said Satchit Balsari, a research fellow at Harvard FXB Center for Health and Human Rights and one of the study’s senior authors.

The researchers found that many people had been displaced from their homes and had endured months without essential utilities, especially in remote areas. Those challenges affected the researchers, too, who downloaded digital map data before traveling to areas that still lacked cell service in early 2018.

The surveyors used offroad vehicles because of the continuing threat of landslides in mountain areas. In part of Culebra, a small island off the main island of Puerto Rico, they arrived planning to interview 35 households. Only one person remained.

“It was a bathroom and half a room,” said Domingo Marques, an associate professor of psychology at Albizu University San Juan, who helped conduct the study with his students and who himself lacked power and running water for months after the hurricane. “All the other houses were gone.”

Those conditions, he said, made clearer why the government’s official death count was incomplete.

“Even if they were really doing a good job, it was really hard unless you did something like we did — go talk to people on the ground,” he said. People, he added, “died alone in their houses. Nobody went there. Some of them were covered by a landslide and months after they’ve not recovered the bodies.”