In a study released Tuesday, the New England Journal of Medicine estimated Hurricane Maria's death toll reached the thousands in Puerto Rico, despite the federal government's official number remaining at 64.
In the days after Maria slammed the island as a near Category 5 hurricane, the island has struggled to return to normalcy. Researchers then compared the post-Maria death rate to that of the previous year and found that the mortality rate was 14.3 deaths per 1,000 residents from September 20 through December 31, 2017, a 62 percent increase compared with 2016, or 4,645 "excess deaths".
The Harvard University-led study was based on a survey of 3300 households that was compared with official figures to determine how many excess deaths took place up to the end of a year ago.
And not a moment too soon, said Carmen Yulin Cruz, the mayor of Puerto Rico's capital city of San Juan.
San Juan Mayor Carmen Yulin Cruz, who has blasted the Trump Administration's response and drew fire from Secretary Pesquera for her questioning of the count past year, tweeted a news story about the findings and hinted at vindication. Given the uncertainties inherent in their survey, the true mortality rate could have been as low as 9.8 deaths or as high as 18.9 deaths per 1000 residents, they wrote.
The researchers used these responses to calculate that between September 20 and December 31, there were about 14.3 deaths per 1000 Puerto Ricans. "Many deaths were caused by poor management of the crisis".
The study notes that its total of 4,465 deaths is likely an underestimate.
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The estimate accounts for direct causes of death due to the hurricane, such as bodily injury or drowning, as well as indirect causes of death: One third of all deaths caused by Maria could be attributed to "delayed or interrupted health care" as well as lack of access to food, water, and other necessities, the study said.
There is a wide margin for error in the study authored by Buckee. That number was about nine times the official death toll. Electricity across the island was lost, and continued to be for months, complicating rescue efforts and communications.
Santos, who based his study on vital statistics records from the Puerto Rican government, said the new report goes further by assessing real-world conditions throughout the island.
Unfortunately, many of these deaths are aptly described as "excess deaths", as both the federal and local government were either vastly unprepared or responded so lackadaisically that one can't help but think of FEMA's management of New Orleans post-Hurricane Katrina.
"It's really commendable that the researchers are providing as much detail as they're doing in their study", he said.
Natalio Rodriguez Lebron, 77, for example, died in Maunabo, Puerto Rico, in January. Still, "The way this is done, by interviews with people in different barrios in Puerto Rico, it seems to me that someone could report a death as associated with the hurricane when it was not".