On September 20 2017, Hurricane Maria made landfall in Puerto Rico,USA, damaging homes, roads, hospitals, and water, power and communication lines.  Though the official death toll stood at less than 60, reports from the island seemed to suggest otherwise. Denied access to these data, Harvard University Professors Caroline Buckee, Satchit Balsari, Rafael Irizzary, and Jennifer Leaning oversaw a household based survey that estimated excess mortality in Puerto Rico from September 20 through December 31, 2017 was closer to 4000, and not 59, as estimated by the US government. 

Aftermath of Hurricane Maria in Puerto Rico (Sept. 28, 2017). Image Source: Andres Kudacki for TIME

The study, published in the New England Journal of Medicine on May 28, resulted in widespread protests across the island. The government of Puerto Rico subsequently revised their estimate to 2,975 (95% CI: 2,658-3,290). The article was the most widely mentioned scientific article across all journals and all disciplines in 2018.

Why was this study done?

On December 9, 2017, the New York Times published an article suggesting that there may have been more than 1,000 deaths. This estimate was based on daily mortality data from Puerto Rico’s vital statistics bureau. The government of Puerto Rico stopped releasing the data after the article was published. Deaths from the hurricane resulted from direct and indirect deaths, as defined by the CDC. Indirect deaths occur due to disruption in healthcare access, transportation, utilities and other consequences of the hurricane. We interviewed 3299 randomly chosen households from across the island, to produce an independent estimate of all-cause mortality after the hurricane, and calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016. 

Why count deaths after disasters?

In a series of articles, we explain why it is important to count deaths after disasters, including the COVID-19 pandemic, where suffering and death result not only from the impact of COVID-19 infection, but also from societal response to the pandemic, including lockdowns and travel restrictions that result in loss of livelihoods, food security, and access to care. In Every Body Counts: Measuring Mortality From the COVID-19 Pandemic, we describe difficulties in disaster death attribution in the United States. In Why Every Body Counts, we describe we argue that the accurate death counting is important not only for closure, but has practical implications on aid distribution, resource allocation and disaster planning. It is important to know who people died, who died and why, in order to plan for an equitable response in the future.

Other mortality studies from our team

“All-cause excess mortality across 90 municipalities in Gujarat, India, during the COVID-19 pandemic”
Rolando J. Acosta, Biraj Patnaik, Caroline Buckee, Mathew V. Kiang, Rafael A. Irizarry, Satchit Balsari 
March 2020-April 2021. PLOS Global Public Health 2(8): e0000824.

This study provides an alternate measure of the mortality shock—both direct and indirect—of the COVID-19 pandemic in Gujarat, India using data from civil death registers from a convenience sample of 90 (of 162) municipalities across the state. This study, using data directly from the first point of official death registration data recording, provides incontrovertible evidence of the high excess mortality in Gujarat from March 2020 to April 2021.

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