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Study: Hurricane Maria and its aftermath caused a spike in Puerto Rico deaths, with nearly 3,000 more than normal

The tombstone of Ricardo Garcia Delgado at a cemetery in the neighborhood of Rio Blanco in Naguabo, Puerto Rico. He died Sept. 24, 2017, after being unable to access dialysis because of power outages caused by Hurricane Maria. (Sarah L. Voisin/The Washington Post)

SAN JUAN, Puerto Rico — Hurricane Maria’s devastation in Puerto Rico led to a spike in mortality across the U.S. territory, with an estimated 2,975 excess deaths in the six months after the storm made landfall in September 2017, according to a sweeping report from George Washington University released Tuesday.

The government of Puerto Rico on Tuesday embraced the GWU estimate as the official death toll, ranking Maria among the deadliest natural disasters in U.S. history. For much of the past year, the government had formally acknowledged just 64 deaths from the hurricane, which ravaged much of the territory and destroyed critical infrastructure. The spike in mortality came as the territory dealt with widespread and lengthy power outages, a lack of access to adequate health care, water insecurity and diseases related to the crisis.

The new study, requested by the governor of Puerto Rico, examined an unusually long period of time following the storm — six months — in an attempt to detect the hurricane’s lingering, indirect effects on mortality. The investigation looked at the total number of deaths from September 2017 through February 2018, and compared it with typical death rates, adjusting for many variables, including the hundreds of thousands of Puerto Ricans who evacuated the territory after the storm struck on Sept. 20.

Following the release of a report, Puerto Rico Governor Ricardo Rosselló raised the island's official toll from Hurricane Maria from 64 to 2,975 on Aug. 28. (Video: Ricardo Rossello)

People continued to die at anomalous rates long after the storm, as the territory struggled with infrastructure failures and political infighting. Nearly 900 excess deaths were reported in January and February of this year. The mortality rates remained high in the poorest areas, the study found.

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The GWU report has a limitation: It does not specify how people died. It is a statistical study based on death records and expected mortality rates. The researchers said they hope to conduct a more detailed investigation in the future.

“We can come up with a hundred different hypotheses,” said Lynn Goldman, dean of the Milken Institute School of Public Health. She offered as an example the long-term lack of electricity, which prevented the use of some medical devices. “What we don’t have is the ability today to tell you these are the factors that caused this.”

The GWU researchers decided to look at six months of data because they assumed that, during that time period, the elevated mortality rate would return to a normal level. But in a briefing at the university Tuesday, the leaders of the research effort said that in low-income areas the mortality rate remained somewhat elevated even after six months. They said further investigation of mortality rates after February could push the estimate even higher.

The GWU report estimates that between 2,658 and 3,290 excess deaths occurred from September through February. The poorer and older the resident, the higher the risk for death, especially among men older than 65.

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Residents of Puerto Rico had been eagerly awaiting the GWU report as a corrective to the implausible official death toll originally embraced by the administration of Gov. Ricardo Rosselló. Rosselló called a news conference Tuesday at the former Spanish colonial fortress that now serves as the governor’s mansion. Journalists packed a room where Rosselló stood flanked by his public safety chief, Héctor Pesquera, who had been the target of public rage for dismissing reports of higher death counts.

The governor accepted the GWU report, which portrayed his administration as unprepared. He acknowledged the government’s shortcomings after the storm and said it is “time to correct what we didn’t do well.” He said he would sign an executive order to revise and reform the government’s protocols for catastrophes and would ask architects at the University of Puerto Rico to design a memorial to honor the hurricane victims.

“I agree I’ve made mistakes,” Rosselló said. “But I reject the notion that this was at all connected to any political consideration. My only consideration was the well-being of the Puerto Rican people.”

The new estimate for Maria’s death toll is significantly higher than the death toll attributed to Hurricane Katrina in New Orleans in August 2005 — 1,833, according to a National Hurricane Center report published that December. Many people drowned in sudden urban flooding there.

In Puerto Rico, the deaths were spread across 18 municipalities, with metropolitan San Juan, western Puerto Rico and the island of Vieques experiencing some of the highest increases in mortality, according to the GWU study.

Many residents were outraged by the government’s intransigence in amending the official toll, even after far higher estimates were released, including a Harvard University survey estimate in the spring that put the number within a range of 800 and 8,000 deaths. The midpoint, 4,645, became a rallying cry for Puerto Ricans who demonstrated on and off the island, most notably by setting thousands of pairs of shoes in front of the Capitol building in San Juan with notes bearing the names of the dead.

Among them was a pair of brown sandals for Teresa Ríos Bacó, who died Nov. 12 after contracting a mysterious illness in the days after the hurricane. The 62-year-old had been clearing debris in front of her home before she started complaining of severe stomach pain.

At the hospital, she was told she had gastroenteritis and was given antibiotics. Then doctors on the USS Comfort medical naval ship diagnosed bronchitis. She didn’t respond to treatment.

At Puerto Rico’s main public hospital, Centro Medico, doctors watched as Ríos Bacó’s skin yellowed, indicating a problem with her liver. Just as doctors sat down to talk to her husband and sons, Ríos Bacó died. The cause, records show, was unspecified liver disease. She was cremated without an autopsy.

Harvard study estimates thousands died in Puerto Rico because of Hurricane Maria

Her husband, Enrique Nelson-Landrón, still has no idea what killed her, but he has his suspicions. His wife, who worked for Puerto Rico’s celebrated music conservatory and led recruitment for its music education programs, showed symptoms of leptospirosis, a bacterial disease found in animal urine, probably rats — a disease that killed at least two dozen people across the territory.

“You don’t know what to believe. It’s the uncertainty that worries me, because of the government’s history of lying,” Nelson-Landrón said. “How it happened is important for me, but she’s still dead.”

Ríos Bacó’s death was not counted among the government’s initial tally of 64 hurricane deaths, and it remains under investigation.

Another person who fell victim to the storm’s aftermath was Ricardo Garcia Delgado, 80, who died four days after Maria hit. He had been in a hospital in the eastern town of Humacao, receiving treatment for a hernia, when the storm knocked out the hospital’s power, which made it impossible for him to receive his life-sustaining dialysis. Three times, medical staff tried to transport him to a different center for dialysis. Hospital officials believe he died en route to Centro Medico in San Juan, said his son, Ricardo Garcia Nieves.

Finding the body and verifying the cause of death proved to be a nightmare for Garcia Nieves and his family. Eventually, Garcia Nieves’s brother found their father’s body in a morgue associated with Centro Medico. The body was then cremated, and Garcia Nieves was unable to confirm how his father died until the hospital mailed him the medical records — about four months after his death.

Garcia Delgado had been the primary caretaker for his wife, who suffered from severe Alzheimer’s. After his death, the family had to place her in a care facility. She died five months later.

Hearing government officials announce the early, low death count in the months after the storm felt “absolutely dismissive,” Garcia Nieves said.

“They’re not even recognizing the real number of people who lost their lives, when we went through the crisis with my father’s body in a freezer,” Garcia Nieves said. “Why, why did they want to downplay the number of people that died?”

The GWU report found that communication problems led to failures in certifying deaths properly during the disaster. Physicians across the territory were not trained and did not know how to appropriately complete death certificates. The government’s failure to communicate proper protocols led to the initial undercount, and the lack of transparency fueled suspicions and rumors.

Planning for communication during a crisis “was very poor,” said the principal investigator of the GWU study, epidemiologist Carlos Santos-Burgoa.

Achenbach reported from Washington.