Puerto Rico: Post-Truth Deaths

From Nishant Kishore and colleagues, in the New England Journal of Medicine:

In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64.

Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016.

From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial.

This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate.

4,645 deaths would make Hurricane Maria the deadliest US natural disaster since the 1900 Galveston Hurricane.

Importantly, this is a survey, and the estimate has a wide confidence interval (as clearly stated by the authors). However, even if we used the lower bound of the confidence interval — 793 deaths — as our estimate of the actual death rate, then the official count (64 deaths) would have understated the death toll by a factor of 10.

There is no excuse for this denial of the truth. The government and other observers had clear evidence that the official death count was absurd. As Arelis Hernández and Laurie McGinley report in the Washington Post,

Gov. Ricardo Rosselló’s administration did not immediately release mortality data nor did officials provide much information publicly about the process officials were using to count the dead. But officials and physicians acknowledged privately that there were probably many, many more deaths and bodies piling up in morgues across the island.

As Kishore et al. note,

the government of Puerto Rico stopped sharing mortality data with the public in December 2017 (our request for these data was also denied)

But it is not just the Puerto Rican government which deserves blame. Perhaps I have missed it, but I cannot find anything from the Centers for Disease Control correcting or even questioning the official death count.

Msterknucklz, a commenter in the Washington Post, said that

This study is designed solely to provide ammunition to those who will point fingers and place blame.

He has missed the point of this study, which was designed to count the dead. The failure of the Puerto Rican and US governments to determine and report a credible death count is in reckless disregard of the truth. We cannot have an informed discussion about public health if we can’t get the facts about something as elementary as mortality.


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