Thousands of people were killed by Hurricane Maria. But the Puerto Rican government has only publicly identified 64 victims.

An investigation by Quartz, Puerto Rico’s Center for Investigative Journalism, and the Associated Press has identified 487 victims of Maria. It is the most extensive record yet of who died and why. Many families say that the real cause of death was government inaction.

Explore the database of victims in English and Spanish here.

One year later, are the federal and local governments any better prepared for hurricane season? “If we have another hurricane of that magnitude, we’re going to get the same level of devastation, give or take,” admitted Puerto Rico governor Ricardo Rosselló in August. “There is no doubt about that.”

Hurricane Maria’s uncounted disaster

In our investigation, family members linked each of the deaths to Hurricane Maria and the island’s damaged infrastructure. But Puerto Rico’s government never did—missing out on key information it might have used to prevent further deaths.

On September 13, 2018, Donald Trump described the official estimate of Irma and Maria-related deaths as a Democratic plot to make him look bad and claimed that the death toll was far lower.

The president visited Puerto Rico for about four hours on Oct. 3, almost two weeks after the storm; according to the Demography Record Institute of Puerto Rico, between September 6, 2017, and the day Mr. Trump left the island, there were 640 more deaths than the average during the same period in the last three previous years.

Youyou Zhou

Here’s a look at the government’s actions, as the death count mounted.

Sept. 20, 2017

Maria makes landfall in Puerto Rico, knocking down power and cell phone service. Federal Emergency Management Agency (FEMA) supplies run out after two days. Eight days later, a CPI investigation confirms that dozens more died than the then-official death toll of 16, and suggests hundreds more. Public Safety secretary Héctor Pesquera denies the report.

Maria makes landfall in Puerto Rico, knocking down power and cell phone service. Federal Emergency Management Agency (FEMA) supplies run out after two days. Eight days later, a CPI investigation confirms that dozens more died than the then-official death toll of 16, and suggests hundreds more. Public Safety secretary Héctor Pesquera denies the report. Oct. 1

Only 5% of Puerto Ricans have power.

Only 5% of Puerto Ricans have power. Oct. 3

Luis Manuel Vázquez Rodríguez is found dead on the floor of his bathroom. The 60-year-old diabetic had been in fine health, says his daughter, but struggled to find insulin after Maria. “Everything was chaos. There was no access to anything, to medicine,” she recalls. “Going to the pharmacy meant kilometers-long lines.”

Luis Manuel Vázquez Rodríguez is found dead on the floor of his bathroom. The 60-year-old diabetic had been in fine health, says his daughter, but struggled to find insulin after Maria. “Everything was chaos. There was no access to anything, to medicine,” she recalls. “Going to the pharmacy meant kilometers-long lines.” Oct. 3

Donald Trump visits the island. “Sixteen people certified,” he said referring to the official death toll at the time. “You can be very proud of all of your people, all of our people working together.”

Donald Trump visits the island. “Sixteen people certified,” he said referring to the official death toll at the time. “You can be very proud of all of your people, all of our people working together.” Oct. 12

US Congress members demand an investigation into hurricane-related deaths. Trump tweets,“We cannot keep FEMA, the Military & the First Responders, who have been amazing (under the most difficult circumstances) in P.R. forever!”

US Congress members demand an investigation into hurricane-related deaths. Trump tweets,“We cannot keep FEMA, the Military & the First Responders, who have been amazing (under the most difficult circumstances) in P.R. forever!” Oct. 12

Joaquín Solivan Ocasio, 43, dies at Manatí Medical Center. Power outages had delayed the diagnosis of a sharp pain in his abdomen for more than 20 days, says his wife. The results arrived two weeks after he died. “My husband had blood cancer—a treatable illness that turned into a death sentence because it wasn’t treated with care.”

Joaquín Solivan Ocasio, 43, dies at Manatí Medical Center. Power outages had delayed the diagnosis of a sharp pain in his abdomen for more than 20 days, says his wife. The results arrived two weeks after he died. “My husband had blood cancer—a treatable illness that turned into a death sentence because it wasn’t treated with care.” Oct. 15

Felipe Figueroa Rosa, 84, wakes up out of breath in the middle of the night. He couldn’t use his sleep apnea machine because of power outages. “We didn’t have a generator,” says his daughter. “I called the ambulance three times and nothing. It never arrived.” He died three days before his flight to leave Puerto Rico.

Felipe Figueroa Rosa, 84, wakes up out of breath in the middle of the night. He couldn’t use his sleep apnea machine because of power outages. “We didn’t have a generator,” says his daughter. “I called the ambulance three times and nothing. It never arrived.” He died three days before his flight to leave Puerto Rico. Oct. 20

Puerto Rico’s government suddenly abandons the emergency response headquarters it had shared with FEMA and other federal agencies. After that, federal and local officials work from different buildings. About 80% of Puerto Ricans remain without power. Suspected cases of Leptospirosis, a bacterial disease transmitted by contaminated water, top 70.

Puerto Rico’s government suddenly abandons the emergency response headquarters it had shared with FEMA and other federal agencies. After that, federal and local officials work from different buildings. About 80% of Puerto Ricans remain without power. Suspected cases of Leptospirosis, a bacterial disease transmitted by contaminated water, top 70. Oct. 20

Alejandro González Vázquez, 46, commits suicide instead of boarding his flight back to the US mainland. Unable to reach his family, he had come to Puerto Rico to check on them, said his niece. But during his stay, Vázquez could not obtain his mental health medication. “Everything he saw here after the hurricane passed affected him,” she said.

Alejandro González Vázquez, 46, commits suicide instead of boarding his flight back to the US mainland. Unable to reach his family, he had come to Puerto Rico to check on them, said his niece. But during his stay, Vázquez could not obtain his mental health medication. “Everything he saw here after the hurricane passed affected him,” she said. Oct. 30

US Navy hospital ship USNS Comfort finally docks in San Juan.

US Navy hospital ship USNS Comfort finally docks in San Juan. Nov. 16

CPI publishes the names of 47 additional hurricane victims. Puerto Rico’s Public Safety secretary dismisses the report.

CPI publishes the names of 47 additional hurricane victims. Puerto Rico’s Public Safety secretary dismisses the report. Nov. 25

Juana Castro Rivera, 52, dies of Leptospirosis. Over the previous two weeks, she’d been to her local clinic several times for pain. She was only diagnosed with the bacterial infection after being taken to a hospital in a neighboring municipality.“It was too late,” said her daughter.

Juana Castro Rivera, 52, dies of Leptospirosis. Over the previous two weeks, she’d been to her local clinic several times for pain. She was only diagnosed with the bacterial infection after being taken to a hospital in a neighboring municipality.“It was too late,” said her daughter. Dec. 20

Puerto Rico’s electric utility has restored just 65% of its pre-storm capacity.

Puerto Rico’s electric utility has restored just 65% of its pre-storm capacity. Jan. 3, 2018

Patricia Nicole Figueroa Colón, 18, is hit by a speeding car as she crosses the street. The street lamps were out and so was the traffic light. “The impact was fatal. They didn’t take her to the hospital. She died on the spot,” her half sister said.

Patricia Nicole Figueroa Colón, 18, is hit by a speeding car as she crosses the street. The street lamps were out and so was the traffic light. “The impact was fatal. They didn’t take her to the hospital. She died on the spot,” her half sister said. Aug. 28

A study commissioned by the Puerto Rican government estimates that 2,975 people died because of Maria. The official list of identified victims remains at 64 deaths, which were reported in December.

Agony in Puerto Rico

After Hurricane Maria, many Puerto Ricans with treatable ailments like bedsores and kidney problems died agonizing and unnecessary deaths, according to dozens of accounts from family members. This was a slow-motion, months-long disaster that continued even as Donald Trump lauded his administration’s response to the category 4 storm.

The chaos that followed in Maria’s wake changed the face of death in Puerto Rico. Young people’s deaths spiked, surpassing the growth in the death rate among the elderly, despite the widespread belief that the hurricane only affected older people and those with preexisting conditions. Deaths from sepsis, a life-threatening complication from infection, rose nearly 44% to 325, compared to the previous three years; kidney-disease-related deaths rose nearly 43%, to 211.

The spikes in deaths due to sepsis and kidney disease are red flags, but they’re only part of the story, as well as other causes of death which rose from 20% to 45% in the three months after Maria: pneumonitis, primary hypertension and renal hypertension, pneumonia and influenza, respiratory disease, Alzheimer’s, heart disease, and suicide.

The victims’ stories help explain what happened. Ramona González, 59, was bedridden due to a degenerative brain disease. In the heat after the hurricane, she started to develop bedsores and couldn’t turn on the air conditioning due to island-wide power outages.

Hospitals in San Juan admitted and released González twice, even though her relatives told doctors they were unable to treat her sores at home. They tried to get her aboard the Navy hospital ship, USNS Comfort. But patients had to be referred for treatment, and Ramona’s sister Maria says she never got the referral.

Ramona died of septicemia on Oct. 20, according to her death certificate.

Deaths that could have been avoided

About half of the hurricane victims in our dataset died in hospitals, which saw a rise in mortality of 32.3%. Many hospitals lacked electricity. Those with generators often lacked the fuel to operate them, according to testimonies collected and observations made by CPI reporters. In dozens of cases collected by Quartz, CPI, and the AP, family members attributed their loved ones’ deaths to a lack of basic medical supplies and services like dialysis and oxygen. Others died in the absence of treatment for chronic diseases such as cancer, Alzheimer’s, and diabetes.

“These are deaths that could have been avoided,” says Cruz María Nazario, an epidemiologist and professor at the Medical Sciences Campus of the University of Puerto Rico.

Puerto Rico has one of the highest rates of kidney failure in the US. Nevertheless, federal and local emergency plans classified dialysis as a relatively low priority, says Angela Diaz, executive director of the Renal Council of Puerto Rico, a non-profit that works to improve conditions for patients with kidney diseases.

Orlando López Martínez, 48, missed four days of dialysis because his treatment center in western Puerto Rico was closed after the hurricane. When it reopened, the center rationed dialysis due to shortages of generator fuel and freshwater. López got less than half his usual treatment.

“In the days after the storm he looked pale, yellowish, really bad,” said Lady Diana Torres, the mother of López’ 10-year-old daughter Paola.

He died on Oct. 10. The official cause of death was a heart attack brought on by kidney disease.

An unplanned emergency response

During Hurricane Maria, Puerto Rico’s Department of Health did not have an emergency response plan that told health institutions and patients what steps to take and where to go for help. Six months before the storm, Puerto Rico’s government consolidated all its emergency response agencies into a single super-agency, the Department of Public Safety, without creating new protocols to replace the old ones. Past emergency response chiefs Epifanio Jiménez and Miguel Ríos have linked the island’s poor disaster response to this abrupt structural change.

Underestimating the hurricane’s damage, the US military deployed a hospital ship, but not enough troops to rebuild critical infrastructure like communications and power lines, said Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University in New York.

“It would have been a perfectly appropriate job for the US military,” he said. “There’s probably no other agency in the world more capable than the US military in re-establishing communications, putting up a temporary electric grid, repairing bridges, making sure that access by ambulance is available.”

Officials from the Department of Health declined interview requests; a spokesperson from the US Defense Department was not able to respond to questions, citing preparations for Hurricane Florence. When ground commander Lieutenant General Jeffrey Buchanan was ordered to leave the island in November, he described the work of rebuilding as unfinished, citing Maria’s size and Puerto Rico’s isolation.

The storm’s young victims

The number of deaths due to accidents spiked in Puerto Rico in the months after the storm.

Accidents and heart attacks were among the causes driving a post-Maria increase in deaths among adults between the ages of 30 and 44. One-fifth of deaths in this age group are still under investigation.

Three weeks after the hurricane, Saúl Pabey Martínez, 27, was electrocuted as he tried to connect a friend’s house to the electrical grid and fell off his ladder, says his mother, Doris Milagros Martínez. He died in the ambulance on the way to the hospital.

A repeat of Maria?

In a retrospective report, FEMA found it had underestimated the food and fresh water needed, and how hard it would be to get supplies to the island. Puerto Rico governor Ricardo Rosselló too has recognized his office’s bungled response, and promised new measures to avoid unnecessary deaths in the future, including a registry for the island’s most vulnerable residents.

But he also says the island is not ready for another Maria-sized event. The electrical grid’s collapse, which our investigation links to more than 150 deaths, is still just as vulnerable, Rosselló said last month. He declined to be interviewed for this story.

It’s also unclear whether the government itself is any better prepared. Puerto Rico’s Office for Emergency and Disaster Management has revised its emergency plan, but refused to provide a copy for review. Puerto Rico’s Department of Health has drafted a new public safety plan, but the agency did not respond to requests for a copy or for an interview. Waddy González, a FEMA official who oversees public health in Puerto Rico, said the plan has not been made public to hospitals or to the public.

Although Puerto Rico’s government has acknowledged that many more people died than originally estimated, it has not released any analysis of the causes of mortality, nor updated the list of victims. Such data is vital to helping the island prepare for future catastrophic storms, say experts.

Before Maria struck, Puerto Rico’s doctors weren’t trained to record disaster-related deaths correctly. (The island’s health secretary, Rafael Rodríguez Mercado, along with the College of Doctors and Surgeons of Puerto Rico, argues it’s not doctors’ responsibility to point out the non-clinical mechanisms that lead to death.) To improve data collection, Puerto Rico’s Institute of Statistics is pushing the government to adopt the Center for Disease Control’s standards for recording disaster deaths. On July 2, the Center for Investigative Journalism sued the Demographic Registry to force it to make all death records public.

Without better methods of recording deaths during an emergency, local and federal authorities run the risk of responding ineffectively to future disasters, says Mario Marazzi, the Statistics Institute director.

“Accurate death tolls matter because they save lives,” he says.

Correction Sept. 14, 6:15pm EST: The number of deaths confirmed in the database is 487, not 488.