Study Puts Puerto Rico Death Toll From Hurricane Maria Near 5,000 
 
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 Updated 12:43 p.m. ET 
 
 Perhaps 5,000 people died in Puerto Rico in 2017 for reasons related to September's Hurricane Maria, according to a study that dismisses the official death toll of 64 as "a substantial underestimate." 
 
 A research team led by scientists at the Harvard T.H. Chan School of Public Health didn't simply attempt to count dead bodies in the wake of the powerful storm. Instead, they surveyed randomly chosen households and asked the occupants about their experiences. 
 
 From that approach, they concluded that between Sept. 20 and Dec. 31, 2017, there were 4,645 "excess deaths" — that is, deaths that would not have occurred if the island hadn't been plunged into a prolonged disaster following the devastating storm. 
 
 But the estimate isn't as precise as the figure implies.The researchers calculate a statistical term called a 95 percent confidence interval, which encompasses a broad range – from 800 to 8,500 deaths. Their figure of 4,645 lies near the middle of that range, and they round up to something over 5,000 to account for some assumptions they made. 
 
 The findings were published Tuesday by The New England Journal of Medicine. 
 
 The research team randomly selected 3,299 households in Puerto Rico. Local scientists surveyed them over the course of three weeks in January. People in those homes reported a total of 38 deaths. The scientists then extrapolated that finding to the island's total population of 3.4 million people to estimate the number of deaths. The researchers then subtracted deaths recorded during that same period in 2016 and concluded that the mortality rate in Puerto Rico had jumped 62 percent in the three months following the storm. 
 
 The death rate is a contentious subject, in part because federal and island governments haven't responded as rapidly to the disaster as they have in other hurricane emergencies. The study notes that 83 percent of the households in Puerto Rico were without electrical power for the time period looked at, more than 100 days, from the date of the hurricane until the end of 2017. 
 
 Puerto Rico residents and outside observers have long argued that the official death toll is hopelessly inadequate. It captures the number of deaths the medical examiner attributed directly to the storm — the high water and howling winds in the worst natural disaster on record for the U.S. territory. Maria came ashore as a Category 4 hurricane, with winds gusting at over 110 mph and drenching rainfall. 
 
 CNN surveyed funeral homes after the storm and tallied 499 hurricane-related deaths. The New York Times compared official death records from September and October 2017 and identified more than 1,000 excess deaths, compared with the average for 2015 and 2016. Alexis Santos, a researcher at Penn State University, and a colleague, used death certificates to come up with a similar estimate. 
 
 The government of Puerto Rico commissioned researchers from George Washington University's Milken Institute School of Public Health to estimate excess deaths. Results of that study have been delayed and are due out this summer. "We have always expected the number to be higher than what was previously reported," said Carlos Mercader, executive director of the Puerto Rico Federal Affairs Administration. He says that's why it commissioned the study from GW. "Both studies will help us better prepare for future natural disasters and prevent lives from being lost." 
 
 Caroline Buckee, a lead author of the news and epidemiologist at the Harvard T.H. Chan School of Public Health, says, "Our approach is complementary to that and it provides a different kind of estimate and a different kind of insight into the impact of the hurricane." The researchers suggested that the government in Puerto Rico could use its methods in an even larger survey to reduce the large uncertainties in their findings. 
 
 The Harvard study covers a greater time period than The New York Times' calculation, a difference that could partly account for the much higher figure. 
 
 The household survey is a widely accepted technique for estimating casualties following a disaster. But it can be misleading if the sample isn't truly random or if some households have been wiped out altogether and are therefore missing from the survey. In the latter, the result would underestimate the true toll. In fact, the Harvard team says its results are "likely to be an underestimate" because of this bias. 
 
 National Communication Issues In Puerto Rico Make It Hard To Register Deaths Communication Issues In Puerto Rico Make It Hard To Register Deaths Listen · 4:04 4:04 
 
 The survey looked at deaths through the end of 2017, but the scientists suspect that the excess deaths continued into this year. "We saw consistent, high rates, in September, October, November, December," says Rafael Irizarry, a biostatistician on the research team. "There's no reason to think that on Jan. 1 this trend stops." 
 
 "Hurricane Maria caused massive infrastructural damage to Puerto Rico," the Harvard team writes in its study. 
 
 "In our survey, interruption of medical care was the primary cause of sustained high mortality rates in the months following the hurricane," the wrote. Hospitals and doctors struggled to provide care, and many people simply had trouble getting to the doctor or the hospital to seek medical care. The survey finds that one-third of the total deaths in the months following the storm were caused by delayed or interrupted health care. 
 
 Understanding the true number is important for many reasons. "There are ramifications not only for families, not only for closure, but also financial ramifications" such as for aid and preparedness, says Dr. Satchit Balsari, one of the lead investigators, who is a physician at the Harvard FXB Center for Health and Human Rights. ||||| Bayamón, Puerto Rico (CNN) In the world of forensic pathology, there's a morbid truism: Bodies are evidence, and you need a body in order to fully examine a death. 
 
 That poses a potentially major challenge for the Puerto Rican government's re-examination of deaths related to Hurricane Maria , which Gov. Ricardo Rosselló ordered Monday after investigations into the official death toll by CNN and other news organizations. 
 
 Thousands of people have died since the storm on September 20, according to the Puerto Rican government. Many, if not most, of those bodies have been buried or cremated. That fact will severely limit the US territory's efforts to re-analyze deaths, experts told CNN. 
 
 "At this point, the bodies have been buried, and there is no way to do a thorough investigation of each individual case," said Eric Klinenberg, director of the Institute for Public Knowledge at New York University and author of a book about deaths following a Chicago heat wave. 
 
 "You'd want to talk with next of kin and neighbors to find out what happened to the person, possibly with doctors as well. But that is very difficult even in the best of times, and right now (many) people still don't have power," he said. "It would require an enormous effort." 
 
 Rosselló said Monday that Puerto Rico's Department of Public Safety and the Demographic Registry will re-examine every death that's occurred since the hurricane, regardless of whether the death certificate lists the hurricane as the possible manner of death. The statement from Rosselló's office, however, did not specify exactly how that review would be conducted. A panel of experts will be appointed to review the process, according to the governor. 
 
 Neither the governor's office nor the Department of Public Safety agreed to an interview on the details of the review. On Wednesday, a spokeswoman for the governor told CNN that details on how the review would be conducted were still being determined and that the matter would be discussed at upcoming meetings. 
 
 The official death toll from Hurricane Maria stands at 64. In reality, it may be many times higher. In November, CNN surveyed half of the funeral homes in Puerto Rico and identified 499 deaths that funeral home directors and staff say were hurricane-related. Later, The New York Times and academics calculated the number of "excess deaths" in 2017 compared with previous years. That analysis led the paper to suggest more than 1,000 people likely died in the storm. 
 
 Puerto Rico's governor said Monday that statistical methods will not be used in reassessing the death toll. 
 
 "A legal process of certification by a coroner or a doctor is necessary, and every family deserves that the case of their loved ones be looked at independently and thoroughly," he said. 
 
 The Bureau of Forensic Sciences, in San Juan, the Puerto Rican capital, is the only laboratory on the island authorized to classify deaths officially as hurricane-related. Pathologists conduct visual assessment and autopsies on some corpses. Documents such as death certificates also can be reviewed, and in some instances family members of the deceased are interviewed. 
 
 After Maria, the forensics bureau reviewed many deaths and autopsied bodies before burial or cremation. But CNN also reported that some deaths possibly related to the hurricane were never sent to the forensics office by doctors or other authorities and therefore never were analyzed. 
 
 The Puerto Rican government could use death certificates to help re-examine deaths, but those documents alone are not enough to classify deaths as hurricane-related, said Dr. Gregory J. Davis, director of the University of Kentucky's Forensic Pathology Consultation Service. 
 
 "Death certificates, unless filled out by an experienced medical examiner/forensic pathologist, are notoriously unreliable," Davis said. Other materials -- including "medical records, police reports, fire/EMS reports, and, though it takes a lot of effort, next-of-kin family statements" -- are needed to make full sense of a death, he said. "It's labor intensive, but if they want the right answers rather than rush answers, they'll do it," Davis said in an email to CNN. 
 
 Scientific methods are the most reliable way to understand how and why a person died, said Dr. Brian L. Peterson, president of the National Association of Medical Examiners. 
 
 And there always could be some dispute about the circumstances of a death -- especially regarding "indirect" hurricane deaths, or those that resulted from the conditions the storm created rather than the high winds and waters associated with the day of the storm, he said. 
 
 "To properly certify a death as other than natural (with respect to manner), we like to have a medicolegal death investigation, an autopsy, and sometimes ancillary studies such as radiology, toxicology, etc.," he said. "More to the point, 'hurricane related' may be more a matter of perception, anyway. Traumatic deaths are easier. Natural deaths are harder to accurately place in the 'hurricane-related' category as death from natural disease may occur at any time." 
 
 Exhuming bodies to do those tests would be expensive and unlikely, he said. 
 
 It also may not help the research, said Davis, from the University of Kentucky. 
 
 "Exhumation is incredibly expensive, involving multiple personnel digging, opening up the vault, bringing up the casket, all with no guarantee that the body won't be quite decomposed or skeletonized, especially in a wet, hot climate such as Puerto Rico's," he said. 
 
 Still, Peterson said, "deaths can always be reviewed at any time" with whatever information is available. Davis said it's possible, although not ideal, to review a death without an autopsy. 
 
 After CNN's investigation, Puerto Rico added two deaths CNN highlighted to the official toll attributable to Hurricane Maria -- that of Quintín Vidal, who died in a fire started by a lantern he was using because of prolonged power outages, and José Rafael Sánchez Román, whose family said he died of a heart attack or stroke during the storm. 
 
 But three additional cases highlighted by the network show how much effort it would take the Puerto Rican government to reassess thousands of deaths that followed the hurricane. 
 
 Earlier this week, the Department of Public Safety told CNN those three additional cases do not warrant inclusion on the list of official deaths. Juan B. Robles Díaz committed suicide because of a pre-existing medical condition, not because of the storm, according to a statement sent to CNN by the Department of Public Safety. 
 
 In a November interview, however, Robles' son told CNN that his father suffered from night terrors in which he ran into the street screaming about how floodwaters were coming back. He sat by a window watching for the moment water would return to wash him away, Carlos Robles said. He told CNN there was no question his father committed suicide because of the stress of Hurricane Maria and its aftermath. 
 
 Yes, he had been diagnosed with cancer, the son said, but that was beside the point. 
 
 Puerto Rico did not add his death to the official tally. 
 
 In the case of Pilar Guzmán Rios, whose family told CNN she died because a breathing machine she required couldn't run without power, and because the insulin that treated her diabetes could not be properly refrigerated, the case was never reviewed by the forensics office "because the doctor certified the deceased on the death certificate as natural," the department said. 
 
 The doctor, Francisco Berio, however, told CNN he made that determination without having seen Guzmán's body, and partly because he wanted her family to be able to bury her more quickly and forensic review would slow that process and prolong grief. 
 
 Investigators "tried to interview the son of the deceased, but the attempts were unsuccessful to the point where the relative did not respond to calls," an emailed statement said. 
 
 About 15% of cellular sites remain nonfunctional because of the hurricane. It's often difficult to receive calls from the mountainous interior of the island, where Guzmán's family lives. 
 
 "The death cannot be attributed to the hurricane," the Department of Public Safety said. 
 
 Finally, José A. Molina's son, Luis Alberto Molina, told CNN in November that his father died of a heart attack because of the stress of running a funeral home after Hurricane Maria. 
 
 The department said it "investigated the case and requested his medical file." "The gentleman had health conditions such as high blood pressure and cardiovascular disorders. On October 8, 2017, he arrived at the hospital due to a chest pain that he was suffering two days before receiving medical attention. Neither the patient nor the relatives in the interview conducted by the doctors in the hospital attribute his situation to Hurricane Maria. Molina died on October 11, 2017. The death cannot be attributed to the hurricane." 
 
 Any death that resulted from the storm or the conditions it created should be counted as part of the official toll, according to Puerto Rican officials. Heart attacks and suicides are included on the official list of deaths that Puerto Rico is attributing to Hurricane Maria. The information matters not only for the accuracy of the count, and the public's understanding of the magnitude of the disaster, but also to families of the deceased. They may be eligible for money from the Federal Emergency Management Agency to cover some funeral expenses. 
 
 "Every life is more than a number, and every death must have a name and vital information attached to it, as well as an accurate accounting of the facts related to their passing. That's the law," the governor said in Monday's announcement. 
 
 Davis, the University of Kentucky professor and medical doctor, said it's worth the effort to examine cases individually. And it's possible with proper funding. 
 
 "It's never too late to try," he said.
– The official government death toll in Puerto Rico from devastating Hurricane Maria stands at 64. A new assessment led by Harvard researchers puts the figure closer to 5,000, reports NPR. More specifically, the researchers calculate that Puerto Rico had 4,645 "excess deaths" between Sept. 20, 2017, and Dec. 31, they write in the New England Journal of Medicine. How they got the figure: Researchers surveyed 3,299 homes in January and February and turned up 38 deaths in the time period after the hurricane, then extrapolated the figure to the island's population of 3.4 million. They concluded with a 95% certainty that the death toll attributable to the hurricane is between 800 and 8,500, with the figure of 4,645 a likely estimate. They also found that when comparing the number of deaths to 2016, the island's mortality rate increased 62% in the three months following the storm. "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 write. The toll of 64 mostly counts people killed directly by rising water or wind, and the Washington Post provides an example of a death that went uncounted. Ivette Leon, 54, died at home in November, less than a day after being released from the hospital. As her condition deteriorated, it took family members 20 minutes to get cell reception to summon help, and then nonworking traffic lights delayed the arrival of an ambulance. The new study suggests there are thousands more like her. "That is an astonishing undercount," a Columbia professor who wasn't involved with the study tells BuzzFeed News. "Something has gone terribly wrong here if they have a 70-times-higher death rate."