THE PROGNOSIS

On its own, Hurricane Maria doesn't seem to have killed a large segment of Puerto Rico's population. The real culprit, it seems, was the loss of electricity, water and cellphone service in the following weeks and months after the hurricane's impact, which fatally deprived thousands of the island’s residents of the medical care they desperately needed.

Puerto Rico’s official government death toll from Maria is 64, but the real number is many times higher, according to a study published yesterday in the New England Journal of Medicine. At least 4,645 people died as an indirect result of the hurricane and its sweeping devastation, researchers at the Harvard T.H. Chan School of Public Health and Beth Israel Deaconess Medical Center have estimated.

Some context from my colleagues Arelis R. Hernández and Laurie McGinley: “The study … found health-care disruption for the elderly and the loss of basic utility services for the chronically ill had significant impacts across the U.S. territory, which was thrown into chaos after the September hurricane wiped out the electrical grid and had widespread impacts on infrastructure. Some communities were entirely cut off for weeks amid road closures and communications failures.”

Here's how the researchers reached their calculation. After surveying 3,300 randomly chosen households across the island, they compared the estimated post-hurricane death rate to the mortality rate for the year before. They found the mortality rate was 14.3 deaths per 1,000 residents from Sept. 20 through Dec. 31, 2017, a 62 percent increase in the mortality rate compared to the previous year.

That translates to 4,645 “excess deaths” that may not otherwise have occurred without Maria. The sizable estimate underscores the terrible shape the island was in for months after the disaster — and how Puerto Rico’s methods for counting the dead led to a severely skewed picture of the hurricane’s real and lasting devastation.

Consider, for example, the tale of Ivette Leon, a 54-year-old mother who died last November about 18 hours after she was released from the hospital. Told by doctors she had an infection and prescribed antibiotics, Leon became short of breath while at home, but her family wasn't able to summon an ambulance in time to save her life.

Here’s how the tragedy went, per Arelis and Laurie: “It took 20 minutes to obtain cell reception and call 911 from their metropolitan Caguas neighborhood,” they write. “It took another 10 minutes, records show, before the ambulance could reach Leon’s home because of road congestion and failing traffic lights.”

“Paramedics tried to revive Leon using CPR, but she was already dead upon their arrival. Montanez tried for days to have an autopsy performed, but she said no government agency or private medical organization had the capacity to conduct one.”

Writing in The Washington Post last month, attorney Mekela Panditharatne relayed her conversations with doctors in Puerto Rico, who described particularly severe problems for the chronically ill.

Wendy Matos, executive director of the University of Puerto Rico’s faculty practice plan, said her clinics were seeing increases in cardiac arrest and intracranial hemorrhage, more waterborne and infectious diseases, and swelling numbers of suicides since Maria.

“Matos, whose doctors comprise the largest network of specialists and subspecialists on the island, also said her medical clinics have lost track of what has happened to tens of thousands of patients since the hurricane,” wrote Panditharatne, an attorney at the Natural Resources Defense Council. 

Sadly, many other Puerto Ricans in need of medical help had similar experiences, as the island’s health-care system remained crippled under widespread and long-lasting power outages. By mid-December 2017, more than one-third of the territory’s 68 hospitals still lacked power. As late as March, 11 percent of its community health centers had limited or no power, according to research by the Kaiser Family Foundation.

“Interruption of medical care was the primary cause of sustained high mortality rates in the months after the hurricane,” the researchers wrote, while calling on patients, communities and doctors to develop contingency plans for natural disasters.

As part of its spending bill in February, Congress provided about $16 billion for Puerto Rico. The cash was still short of the $94 billion Gov. Ricardo Rosselló said was necessary for the island's recovery — and some Democrats took advantage of yesterday’s report to issue more criticism along those lines.

House Minority Whip Steny Hoyer (D-Md.) called it “deeply alarming and upsetting” that the hurricane probably caused the deaths of thousands of Puerto Ricans instead of just dozens. “That many of these deaths were preventable and due to inadequate provision of emergency resources and medical care is even more disturbing,” Hoyer said in a statement.

Carlos Mercader, executive director of the Puerto Rico Federal Affairs Administration, said yesterday that the territorial government welcomes the new survey and looks forward to analyzing it.

“As the world knows, the magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities,” Mercader said. “We have always expected the number to be higher than what was previously reported.”

AHH, OOF and OUCH

AHH: The Virginia Senate appears to have enough votes to break through years of GOP resistance and expand Medicaid to 400,000 low-income residents as part of a budget vote planned for today, The Post's Laura Vozzella reports. After wrestling with the issue for the past four years, the Virginia House of Delegates passed a spending plan in February with expansion. And supporters say they have the votes they need to do the same when the full Senate meets Wednesday.

"Supporters consider expansion a moral and economic no-brainer, since the federal government is offering to pay 90 percent of the cost," Laura writes. "Opponents, fearful that Washington will renege on the funding and stick Virginia with the whole $2 billion-a-year tab, call it financially irresponsible."

Senate Majority Leader Thomas Norment made an unsuccessful last-ditch effort yesterday to try to block Medicaid expansion for yet another year, trying to advance in the Finance Committee a budget without Medicaid expansion instead of another version including it. But his parliamentary maneuver was ultimately ruled out of order. 

OOF: Yesterday, the Supreme Court declined to take up an Arkansas law that challengers say could end the use of medication abortions in the state, The Post's Robert Barnes reports. Under the law, doctors who provide medication abortions must have a contract with a specialist who has hospital admitting privileges.

While the Supreme Court overturned a similar Texas law two years ago that required doctors who provided abortions to have admitting privileges in a local hospital, a panel of the U.S. Court of Appeals for the 8th Circuit has upheld the Arkansas law. Challengers can still ask a judge to strike down the law, but may have to prove how many women could be affected by it.

“Abortion providers say the requirement is burdensome and unnecessary because complications are extremely rare from the two-pill regimen that is used in the first nine weeks of pregnancy, and any that do arise can be handled by a local emergency room or hospital,” Robert writes. “The state has only three abortion clinics, and two of those offer only medication abortions. So the law could leave only one clinic, in Little Rock, to serve the entire state — and it would have to offer only surgical abortions.”

OUCH: The World Health Organization said it is “cautiously optimistic” about the success of its efforts to stop the spread of Ebola in the urban area of the Congo. But the Associated Press notes the virus has also been reported in two remote areas.

WHO emergencies chief Peter Salama said the response has gone “quite smoothly.” “We can’t conclude we have safeguarded the city of Mbandaka, but so far there hasn’t been an explosive increase in cases ... We have reason to be cautiously optimistic,” he told reporters. He said the first priority is to curb the diseases in Mbandaka, a city with more than 1 million people.

The United Nations health agency has worked with partner organizations to vaccinate more than 400 people with an experimental Ebola vaccine. There have been 35 confirmed cases of the disease, including 12 deaths. Salama also told reporters that, pending approval, officials are considering testing five unlicensed drugs for Ebola, two of which have been used in prior outbreaks, and three that have mostly been tested in animals.

TRUMP TEMPERATURE

— Today, President Trump, Health and Human Services Secretary Alex Azar and Ivanka Trump will attend the White House Sports and Fitness Day. Administration officials said on a call with reporters that the goal is "to ensure that all American children are given the opportunity to compete and gain the developmental benefits of participating in sports."

HEALTH ON THE HILL

— Yesterday, Sen. Bill Cassidy (R-La.) announced a new set of proposals to lower health care costs, which include creating price transparency for patients, addressing “surprise” medical bills and eliminating “gag clauses” banning pharmacists from telling customers about the availability of lower-cost drugs. The Louisiana Republican also blamed Democratic partisanship for the failure of efforts to shore up Obamacare’s insurance exchanges by passing two formerly bipartisan stabilization bills.

“The good news is that it’s absolutely possible to fix this mess by ending the rules that rig the system for the companies with all the lawyers and lobbyists, and giving patients the power to choose what is best for them,” Cassidy said. “The bad news is that the U.S. Senate is split almost evenly, and Washington Democrats refuse to work with us to make things better.

“We saw Senator Nelson ultimately oppose Collins-Nelson, a bipartisan agreement he helped initiate,” he added. “We saw Senator Murray ultimately oppose Alexander-Murray, a bipartisan agreement she helped initiate. Why did they do this? Election-year politics, plain and simple.”

INDUSTRY RX

— In a landmark settlement, federal antitrust regulators will allow German pharmaceutical giant Bayer and agricultural company Monsanto to merge after the two companies agreed to spin off $9 billion in assets, our colleagues Brian Fung and Caitlin Dewey report. Bayer will sell its seed and herbicide businesses to a third party, German chemical company BASF. It will also sell off its emerging digital farming business and some of its intellectual property and R&D projects.

“The targeted spinoffs are aimed at preventing Bayer and Monsanto from using their combined control over seeds and seed treatments to raise the price of agricultural products to farmers and consumers, Justice Department officials said,” Brian and Caitlin write. “Just six companies, including Bayer and Monsanto, have historically dominated the global trade in seeds and agrochemicals.” Antitrust officials have been investigating the deal for more than a year.

— The chief executive of Athenahealth Inc. has issued an apology following a report that he attacked his ex-wife more than a decade ago. The apology follows a report from the Daily Mail that Jonathan Bush, a nephew of former president George H.W. Bush, had struck his ex-wife Sarah Seldon in the sternum and once gave her a black eye, according to 2006 court documents. Athenahealth was made aware of the allegations after the Daily Mail contacted the company on Friday, Bloomberg News’s Emma Ockerman reports. Bush continues to serve as the company’s CEO.

“I take complete responsibility for all these regrettable incidents involving my dear former wife,” Bush said in a statement. “I have worked very hard since then to demonstrate my remorse, and today, Sarah and I have a strong, co-parenting relationship. I accept responsibility for my conduct and apologize to everyone involved.”

Seldon, in a separate statement, acknowledged the incident and added that it “is part of his and our family history; however, it should not define Jonathan as a person, or our relationship overall.”

— A few more good reads from The Post and beyond:

MEDICAL MISSIVES
Health & Science
Two doctors blamed a kayaking injury. A scan eventually revealed something much scarier.
Sandra G. Boodman
A study involving the search engine Bing shows how artificial intelligence might detect medical conditions traditional medicine misses.
Wall Street Journal
STATE SCAN
An alarming increase in the use of a highly toxic and banned pesticide at illegal marijuana farms hidden on public land in California is leading U.S. and state officials to team up on an issue that recently divided them: pot.
AP
OPIOID OPTICS
Claire McCaskill, the Democratic senator from Missouri, has spent the past 18 months investigating drug makers and distributors to determine what role they played in furthering the opioid crisis. But her investigation into the Israeli drug company Teva — the world’s largest manufacturer of generic drugs — has largely been thwarted.
Stat News
DAYBOOK

Today

  • The Health IT Expo begins.
  • The National Cancer Institute’s Rural Cancer Control Meeting begins.
  • The Johns Hopkins Bloomberg School of Public Health holds a panel discussion on alternatives to animal testing.

Coming Up

  • The NIH Pain Consortium Symposium begins on Thursday.
  • AHIP holds a webinar on telemedicine on Thursday.
  • The 2018 American Society of Clinical Oncology annual meeting begins on Friday.
SUGAR RUSH
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