Nearly nine months after Hurricane Maria hit the shores of Puerto Rico, knocking out power for more than 3 million residents, shutting down hospitals and clinics, and destroying crops across the island, the number of people killed by the storm — and the public health crisis in its aftermath — remains a matter of debate. 

A team of Harvard researchers weighed into that debate on Tuesday, releasing a study that found that the death toll in the three months after the storm hit is an estimated 4,645 people — and may have even exceeded 5,000 people. 

This number contradicts official government statistics, which indicated a mere 64 deaths between October and December of 2017, NPR reports.  

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“Our results indicate that the official death count of 64 is a substantial underestimate of the true burden of mortality after Hurricane Maria,” the authors of the study wrote. “Our estimate of 4,645 excess deaths from September 20 through December 31, 2017, is likely to be conservative since subsequent adjustments … increase this estimate to more than 5,000.” 

The study polled more than 3,000 households from neighborhoods across the country, and then compared statistics to 2016 mortality rates in order to determine the number of “excess deaths” caused by the storm. 

The authors attributed the increased mortality rate to “interruption of medical care,” which they wrote was the “primary cause of sustained high mortality rates in the months after the hurricane.” 

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In the immediate aftermath of the storm, which hit the island last September, about half of the island’s hospitals were forced to shut down and many local clinics ran without power or clean water for months. 

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And it wasn’t just access to health care that was affected.

Hurricane Maria also damaged water systems — leaving as many as 1 million Puerto Ricans without clean water about a month after the storm, and putting them at risk of various water-borne illnesses. In addition, toxic mold threatened the health of the estimated 15% of Puerto Ricans who suffer from asthma

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These conditions came in the context of preexisting health care challenges in Puerto Rico, where more than 2 in 5 people live below the federal poverty line. 

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According to statistics from the Kaiser Family Foundation (KFF), the number of Puerto Ricans who reported having only fair or poor health was nearly twice that of the mainland, and the proportion of Puerto Ricans with a disability was also double that of the contiguous United States. 

Puerto Ricans were 50% more likely to suffer from diabetes than those on the mainland, according to KFF. 

Read More: Things Are Still Really Bad in Puerto Rico

As the next hurricane season approaches, the authors of Harvard study urged the US to “review how disaster-related deaths will be counted, in order to mobilize an appropriate response operation and account for the fate of those affected.” 

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Hurricane Maria May Have Killed 5,000 People in Puerto Rico: Harvard Study

By Phineas Rueckert