Post-Maria Death Toll Vastly Underestimated in Puerto Rico

Troy Brown, RN

May 29, 2018

The true number of excess deaths attributed to Hurricane Maria in Puerto Rico is estimated at 4645 — more than 70 times the official death count of 64, a new study shows. Researchers believe the actual number of related deaths may exceed 5000.

Nishant Kishore, MPH, from the Department of Epidemiology and Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, and colleagues reported their data in an article published online May 29 in the New England Journal of Medicine.

In a press release issued the same day, Carlos S. Mercader, executive director of the Puerto Rico Federal Affairs Administration, said the government welcomes the new data. "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.” He also noted that the government has commissioned a study by George Washington University on the fatalities that is still ongoing.

The researchers surveyed a randomized group of 3299 households in Puerto Rico stratified by remoteness, which they defined by travel time to the closest city with a population of 50,000 or larger. They left personal identifiers out of the survey and did not compensate participants.

Accurate Mortality Data Collection Difficult

From September 20 through December 21, 2017, the mortality rate increased by 62% compared with the same period during 2016, for an annual mortality rate of 14.3 deaths per 1000 persons. (95% confidence interval, 9.8 – 18.9).

Thousands more were displaced from their homes, evacuated elsewhere in Puerto Rico (52%) or to the US mainland (41%).

"Accurate estimates of deaths, injuries, illness, and displacement in the aftermath of a disaster such as Hurricane Maria are critical to the immediate response, as well as for future risk reduction and preparedness planning. However, public health surveillance is extremely challenging when infrastructure and health systems are severely damaged," the authors explain.

Not All Deaths Directly Related to Catastrophic Event

Interruption of medical care was the primary reason for the continued high mortality rates that lasted months after the hurricane, and a similar pattern after natural disasters has occurred in the United States after Superstorm Sandy and Hurricanes Katrina, Harvey, and Irma.

Almost a third (31%) of Puerto Rican households reported at least one problem with disrupted medical care, including lack of access to medications (14.4% of households), needing electricity-requiring respiratory equipment (9.5%), closed medical facilities (8.6%), or absent physicians (6.1%). Of households in the most remote areas, 8.8% said they had been unable to access 911 services by telephone.

"Growing numbers of persons have chronic diseases and use sophisticated pharmaceutical and mechanical support that is dependent on electricity," the researchers explain. "Chronically ill patients are particularly vulnerable to disruptions in basic utilities, which highlights the need for these patients, their communities, and their providers to have contingency plans during and after disasters."

"We found a strong positive association between remoteness and the length of time without electricity, water, or cellular telephone coverage," they write.

Homes went an average of 84 days without electricity, 68 days with no water, and 41 days without cellular telephone services between the hurricane and December 31, 2017. In the most remote areas, 83% of households had no electricity during the entire period.

Although the timely and accurate determination of the death toll after a natural disaster is vital for public health and disaster-response planning, the disaster-relatedness of these deaths makes accurate death information important for families to reach emotional closure, acquire disaster-related aid, and develop resiliency, the authors explain

"As the United States prepares for its next hurricane season, 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," the researchers conclude.

The authors have reported no relevant financial relationships.

N Engl J Med. Published online May 29, 2018. Full text

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