4 takeaways on Puerto Rico’s death toll after Trump’s tweet storm “3000 people did not die” in Puerto Rico, the president tweeted.

This story is from Kaiser Health News.

President Donald Trump took to Twitter on Thursday morning to challenge the official count of the number of people who died in Puerto Rico in the aftermath of Hurricane Maria, which struck nearly a year ago.

“3000 people did not die” in Puerto Rico, the president tweeted.

The death toll from the Sept. 20 storm, a Category 4 hurricane, has been a point of contention between officials and residents who live there. George Washington University (GWU) researchers released the findings of an in-depth investigation commissioned by Puerto Rico’s government. They estimated 2,975 people died as a result of the storm.

The president questioned that report’s credibility, insinuating that the count was a ploy by his political opponents and that it included people who died from causes unrelated to the storm.

“This was done by the Democrats in order to make me look as bad as possible when I was successfully raising Billions of Dollars to help rebuild Puerto Rico,” he tweeted. “If a person died for any reason, like old age, just add them onto the list.”

The tweets prompted a sharp rebuke from Puerto Rico Gov. Ricardo Rosselló, who called for recovery efforts to remain above the political fray.

“The victims and the people of Puerto Rico do not deserve to have their pain questioned,” the governor’s statement said.





Here is a brief look at the issue of casualties and Puerto Rico’s response to Hurricane Maria.

How many people died?

Calculating a death count is not an exact science. Estimates are influenced by a variety of factors including the period analyzed and the definition of a disaster-related death, according to Columbia University professor John Mutter.

The Puerto Rican government accepts GWU’s estimate of 2,975 deaths as the official count. Local officials had originally said 64 people died in Hurricane Maria, counting only fatalities directly attributable to the storm, such as drowning deaths or mortal injuries caused when buildings collapsed. During the summer they acknowledged that toll had risen to more than 1,400.

The GWU researchers calculated their estimated death toll, which is about double that tally, by comparing the number of people who died in the six months after Hurricane Maria to historical averages in previous years.

The university issued a statement Thursday, disputing Trump’s comments. The investigation was “carried out with complete independence and freedom from any kind of interference,” according to the press release.

Prior to the GWU study, other researchers and one newspaper released estimates that also garnered media attention.

One study, published in the New England Journal of Medicine, put the number of excess deaths at 4,645 in the three months following the hurricane. A study by The New York Times used vital records from the government to calculate an excess of 1,052 deaths in the first 42 days after the disaster.

Still, the numbers are important, said Mutter, who researches disaster management and worked on collecting the number of deaths in New Orleans after Hurricane Katrina. These death counts are a key way the public measures a disaster and perception drives donations for relief, he said.

Why was it so confusing getting a death toll?

When Hurricane Maria made landfall in Puerto Rico, it devastated the island’s infrastructure, which can limit access to health care and impact mortality, especially among residents who are frail or dealing with chronic health issues.

The storm knocked out electricity for the entire island, which took nearly a year to restore fully. At least 80 percent of communications towers were not operational, crippling phone services. Medical centers across the island relied on generators for power, which sometimes failed and jeopardized patients. Some medical facilities in Puerto Rico were irreparably damaged, like the only hospital on the island of Vieques, which housed its only dialysis center. Residents must now leave the island three times a week for treatment.

Many roads on the island were impassable because of debris or erosion. Roads near rivers, like those in the mountainous, rural province of Utuado, washed away. Bridges also fell, leaving some communities isolated and unable to access assistance.

Hurricane Maria also cut off drinking water to more than half of Puerto Rico. The lack of electricity meant water pumps could not work. Some people turned to other sources, like natural springs and rivers, for drinking water. At least 26 people died of leptospirosis, a bacterial infection caused by exposure to water or soil contaminated with the urine of infected animals, according to reporting from CNN and the Centro de Periodismo Investigativo, a nonprofit group that promotes investigative journalism.

In addition to the physical disruption, the GWU researchers noted that officials in charge of certifying deaths did not have a process that automatically noted when a death was a consequence of the hurricane or its aftereffects.

How did the federal government do in its response to Hurricane Maria?

According to the federal government, not very well.

A report released earlier this month by the U.S. Government Accountability Office (GAO) details how the Federal Emergency Management Agency (FEMA) struggled to meet the needs of Puerto Rico and the U.S. Virgin Islands after the storms.

The agency didn’t provide adequate staffing to the disasters on the islands, according to the GAO. It faced a 37 percent staffing shortage as of Sept. 1, 2017. Of the personnel deployed to the islands, some “were not physically able to handle the extreme or austere environment of the territories,” the report said. The lack of bilingual employees also led to delays since many Puerto Ricans speak Spanish.

Transporting materials to the island was also an issue for the agency, as both islands are located more than 1,000 nautical miles from the mainland, the report said.

FEMA Administrator Brock Long addressed some of those issues Tuesday in an interview on CNN. “We threw as much as we could towards Puerto Rico,” he said.

He added that FEMA’s prime concern is preventing deaths from natural disasters, but also that “there’s a difference between direct deaths of, you know, the winds, water, collapsed buildings, things that kill people directly versus the indirect deaths. Indirect deaths are always higher than the direct deaths after many events. … But what I really believe is that we have to concentrate on the pre-disaster mitigation, fix the infrastructure that was crumbling before the storms in the commonwealth, so that we prevent this from ever happening again.”

He noted that FEMA is now the largest employer in Puerto Rico as repair efforts continue.

What has the Puerto Rican government done in response to the death counts in Hurricane Maria?

After the GWU findings were released, Gov. Rosselló changed the official death count and accepted responsibility for the territory government’s failure to adequately respond to residents’ needs. He also said he would form a commission to consider the recommendations suggested in the GWU study on how to improve the island’s response to disasters.

However, how many changes the territory’s government can make remains to be seen. Puerto Rico’s purse is under the control of a fiscal oversight board put in place by Congress to address the island’s debt crisis, which stands at more than $70 billion.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.