Death toll disparity in Puerto Rico: why accurate numbers matter

Rebeka Rodríguez leans over the car console to help navigate her hand-drawn map of this small, hard-to-reach neighborhood in Adjuntas, a western mountain town. The curving pencil strokes demarcating homes and streets, and landmarks like chicken coops and bridges, don’t note the steep roads, or where they’re riddled with nearly impassable potholes. Even the paved parts were washed out during Maria.

But the color-coded key does show which households are inhabited by people reliant on medications that require refrigeration. A handful of homes are outlined in orange, meaning they’re “extremely urgent” cases – families left extra-vulnerable by hurricane Maria, whom Ms. Rodríguez’s organization worked to connect with solar power.

A new hurricane season kicks off today, but Puerto Rico is still reckoning with Maria’s deadly aftermath. A report published in The New England Journal of Medicine this week found that the death count could be some 70 times higher than the official numbers released by the Puerto Rican government last December.

Roughly 4,600 people may have died in the months following the Sept. 20 storm, according to researchers from Harvard’s T.H. Chan School of Public Health – many from delayed or unavailable medical care after Maria. That’s compared to the 64 deaths attributed to the storm by the government. The disparity could come down to a number of factors, experts say, ranging from a very strict definition of what qualifies as a disaster-related death to political posturing.

But an accurate estimate of deaths following a natural disaster like Maria is vital for future response planning. Earlier this spring, damage to a single power line plunged the entire island into darkness once again, demonstrating how vulnerable Puerto Rico remains as hurricane season kicks off anew.

“A lot is at stake with underreporting” the death toll, says Satchit Balsari, a lead investigator on the study and a research fellow at Harvard’s FXB Center for Health and Human Rights. “At the very least, [an accurate number] means closure for the family of a victim.” But it also affects funding and planning that can take into account where people died on the island, and why, helping first responders identify and prepare for areas most at risk in the future.

“The ramifications for future hurricanes are substantial,” Dr. Balsari says.

Keeping the lights on

The Harvard study found that one-third of deaths in the months following Maria were due to delayed or interrupted health care, and that 83 percent of homes in Puerto Rico were without electricity for more than 100 days after the storm. That’s especially dangerous for people who depend on medication that requires refrigeration, or electrical devices like oxygen and dialysis machines.

In line with communities across Puerto Rico, Ms. Rodríguez and the organization where she volunteers, Casa Pueblo, took it upon themselves to identify families most at risk to lend a vital hand. It became clear neighborhoods like the one she mapped – far removed from the town center, hard to reach by car or on foot, and inhabited by many elderly and poor residents – were extremely vulnerable to the storm’s aftermath.

“There’s a lot of inequality in Puerto Rico, but it’s something hidden,” says Alexis Massol González, Casa Pueblo’s co-founder. “And when it’s out of sight, it’s easier to overlook the vulnerable.” 

Before Casa Pueblo learned of Isabel Rivera Torres and Juan Cardona Lopez’s living situation in Adjuntas, their son would go between their home and town three times a day to bring ice to keep Ms. Rivera’s insulin cold. Mr. Cardona is going blind, and they have a disabled adult daughter who doesn’t speak also living with them. They relied on the generosity of neighbors – struggling just like them to stay hydrated, fed, and healthy – to survive in the weeks following Maria.

The organization identified 10 homes like theirs to deliver solar panels, a small solar fridge, and solar lamps so that homebound residents could stay up past sunset – in the case of Rivera and Cardona, playing dominoes on their kitchen table to pass the time.

The hope is that if there’s a “next time,” the most at-risk homes will already be on the radar of those involved in community response here, Rodríguez says.

“This is really common,” says John C. Mutter, a professor of environmental science and public affairs at Columbia University. “The first person you will see after a disaster is most likely to be another citizen. That empowers citizens [to help each other] and it should,” he says.

“But that isn’t a way in which a government can absolve its responsibility for doing something in terms of recovery.”

Push for accuracy

Professor Mutter has studied how deaths are counted after natural disasters, including hurricane Katrina in 2005. He says the Harvard study, which was conducted in just a few weeks for roughly $50,000 – quick and affordable by research standards ­– was “sound.”

The research team randomly selected 3,299 homes on the island, or about 9,522 people, to survey in January. People interviewed in these homes reported 38 deaths between Sept. 20, when Maria made landfall, and Dec. 31, 2017: a 62 percent jump in mortality rate compared to the same period in 2016. They then applied that rate to Puerto Rico’s overall population (3.4 million) to estimate the total number of deaths.

“There is no uniform way to do a death count” after a natural disaster, Mutter says. “In some cases, a government might make up numbers, like Haiti,” he says of an original death toll after the 2010 earthquake, which hovered around 300,000 people. Later that was lowered to closer to 50,000 deaths. There’s an incentive in overestimating a death toll, especially in poorer places.

“The really odd part is knowing that donations for people affected by disasters go with the number of people killed. That’s where the sympathy lies after a disaster – with the dead and injured,” he says.

The death toll given by the island’s government has puzzled – and angered – many.

The low count could come down to how narrowly disaster deaths are defined, such as whether deaths from delayed treatment are recorded as storm-related. Or that the government requires that all disaster-related deaths be examined by Puerto Rico’s Forensic Sciences institute, located in San Juan: a challenging request compounded by prolonged electricity and cellular outages, blocked roads, and limited access to medical facilities after the storm.

But some, including San Juan Mayor Carmen Yulín Cruz, are now questioning if the official death count was an attempt at a “cover up,” or if it was a way for Gov. Ricky Rosselló to pander to President Trump, who praised the island for its low death toll.

Earlier this year, a team of investigative reporters in Puerto Rico took the island’s Department of Health and Demographic Registry to court, demanding mortality data beyond November 2017, the last month the data was made publicly available.

Some new steps have been taken in preparing for this hurricane season, including upgraded communications systems like satellite phones in each municipality, reports Buzzfeed News. But there haven’t been plans made public by the Federal Emergency Management Agency or the Puerto Rican government as to how the island’s most vulnerable residents will be helped in the case of another emergency.

“Communities were isolated, and they used their own force to clean and open roads. It’s led to the biggest social movement in Puerto Rico’s history,” says Mr. Massol from Casa Pueblo of Maria’s longer-term effects. “But Maria also marks a collapse on the side of the government. Can they match this community solidarity?”