A woman places a shoe in memory of those killed by Hurricane Maria in front of Puerto Rico’s Capitol on Friday. (Ramon Espinosa/AP)
Armando Valdés Prieto is a lawyer and political consultant in San Juan, Puerto Rico, and a former director of Puerto Rico's Office of Management and Budget.

SAN JUAN, Puerto Rico — In the wee hours of Wednesday, Sept. 20, 2017, with 150-mph winds howling outside, my wife, who was then six months pregnant, slipped and fell as we tried to leave the basement of my in-laws’ house, which was slowly flooding. A fall during any stage of a pregnancy is serious business, and though she wasn’t in any pain nor showed signs of any obvious injury, a visit to the doctor is standard practice. So, two days later, she headed to the hospital, where in December our daughter would be born, happy and healthy.

The hospital was already showing signs of just how woefully unprepared Puerto Rico’s health-care system was to face the unfolding emergency that Hurricane Maria’s winds, rains and floods had brought. Outside the hospital, one of San Juan’s premier institutions situated in the wealthy Condado neighborhood, the tropical sun shone brightly. During the daytime, it almost looked like a nice day to sprawl out on the powdery white sands of the nearby beach. But inside it was a wholly different story.

Electricity was down across the island, so the hospital was running on generators that were insufficient to power even the basic essentials. The central air-conditioning system was inoperative, and next to the stall where my wife was laid down to be evaluated, a woman was in her 36th hour of labor. The heat was unbearable, as can only happen when you trap stale air and Caribbean temperatures in a hermetically sealed building. One portable HVAC unit was pumping cool air into the maternity ward in a futile effort to provide comfort to the patients and staff. My wife’s doctor was unreachable, as all the phone systems had collapsed, so we feared she would have to spend the night in those insalubrious conditions. Thankfully, at the last minute, the nurses were able to reach her obstetrician, and she was discharged that night.

We were fortunate: Everyone was healthy, and we got out of the hospital quickly. Compared with the pain of thousands of families who lost loved ones, our experience was insignificant. But it is why the report published last week by Harvard researchers in the New England Journal of Medicine disclosing how many people died here after the storm came as no surprise to me. Many people wonder, even folks here on the island, how the deaths of so many, weeks and months after Maria, could have any relation to that storm; how, after the catastrophe had passed and under a cloudless blue sky, could people still be dying. Our brief interaction with a crippled health-care system showed just how much went wrong.

The report finally uncovered the truth about the local government’s official death toll of 64. The authors’ conclusions: At least 793 deaths — and possibly up to as many as 8,498 — went uncounted between September and December, and “one third of the deaths were attributed to delayed or interrupted heath care.” Under public pressure, Puerto Rico’s government on Friday finally put out information it had denied Harvard’s researchers. According to the Commonwealth’s Demographic Registry, between September and December of last year, 1,397 more deaths were reported than in the same months of 2016, despite increased emigration as a result of the conditions on the island after the hurricane.

Neither the commonwealth nor the federal government appear to have been aware of the reality on the ground. It’s as if officials were either intent on measuring their success in dealing with the emergency in terms of how many people died, or were oblivious to the fact that not all hurricane-related deaths are caused by falling trees, drownings and other immediate storm effects. President Trump essentially admitted the former during his visit to Puerto Rico, when he asked Gov. Ricardo Rosselló about the number of deaths — then “certified” at 16, according to Rosselló — and compared it favorably to what happened in “a real catastrophe like Katrina.” The latter was most tactlessly admitted by Puerto Rico’s health secretary, who nine days after the storm said on a local radio station that “people die in hospitals every day for any number of reasons.” He added that these were “things that are unavoidable.”

Despite those assertions, many of us did try to avoid the seemingly unavoidable. I helped coordinate a municipal effort, initiated by San Juan Mayor Carmen Yulín Cruz, to provide basic needs and medical care for elderly residents of low-income housing projects across the capital. (Cruz appointed me to an unpaid position on the board of a foundation she established to support hurricane relief.)

We found an ongoing human disaster during the months of September, October and November, when we made daily visits to more than 60 senior homes and independent-living facilities. At one high-rise, within walking distance of a hospital, residents were trapped on the upper floors because the backup generator had failed and they couldn’t walk down the stairs. Some folks I spoke with didn’t remember when they had last eaten. There was no potable water because the pump to get it up to the apartments also depended on electricity. Dialysis patients hadn’t been treated in days; diabetics couldn’t refrigerate their insulin.

At that facility, four days after the storm, one man who must have been older than 80 begged me to take him to a shelter — not because he was afraid of the storm’s effects on his home, but because he couldn’t walk up and down the stairs to his ninth-floor apartment to buy food. Another man, whom we found lying on the floor in the building’s common area wrapped in a blanket, was taken to a hospital only to be discharged because the facility couldn’t perform more than the most basic tests; the backup generator couldn’t handle any imaging or power more sophisticated lab equipment.

The hospital couldn’t reach ambulance services for other residents who needed urgent care, because they had no means of communication. A nearby police car was similarly incommunicado. Four people were eventually evacuated from the building in municipal ambulances — stretchers and wheelchairs were carried down cramped stairwells — but I overheard the EMTs wondering where they would take the dialysis patients; they didn’t know if any centers would be open.

With conditions that bad at one of so many buildings, of course more than 64 people died. What is surprising is that the government has so far been unwilling to admit it. We have to learn from our mistakes to avoid them in the future and to honor those who died so senselessly.

This past weekend, as a growing number of Puerto Rican families gathered on the north end of the Capitol in San Juan to place shoes in an evocative and moving memorial to those many hundreds or thousands who were lost, I saw a heartbreaking image on Twitter. There was a small pair of socks, in the middle of this improvised monument, and a note that read: “Isaías, recién nacido de Adjuntas. No salió del hospital.” “Isaías, newborn from the town of Adjuntas. Didn’t leave the hospital.”

As I read that, I could only think of my own daughter, Lila, who did make it out. And I could only wonder if that woman next to us in the maternity ward that day, who suffered through labor in unconscionable conditions, might have been Isaías’s mother.

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