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The Hurricane Maria death toll President Trump denied, explained

President Donald Trump and first lady Melania Trump take a walking tour with Puerto Rico Governor Ricardo Rosselló, left, and his wife Beatriz Areizaga, to survey hurricane damage and recovery efforts in a neighborhood in Guaynabo, Puerto Rico, Tuesday, Oct. 3, 2017. (AP Photo/Evan Vucci)

The governor of Puerto Rico and disaster mortality experts are pushing back against President Donald Trump’s claim that the official death toll from Hurricane Maria was inflated by Democrats to make him look bad.

“It’s not time to deny what happened. It’s time to make sure it doesn’t happen again,” Gov. Ricardo Rossello said in a statement.

Trump lashed out early Thursday amid cable news coverage critical of his assertion that the federal response to Hurricane Maria last September was an underappreciated success, alleging that the death toll was increased from 16 to 2,975 long after the storm to hurt him politically.

“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. If a person died for any reason, like old age, just add them onto the list,” Trump tweeted, adding, “Bad politics. I love Puerto Rico!”

The 2,975 figure is an estimate and it is not based on documented causes of death, but the research team responsible for it stands by the finding.

“Our results show that Hurricane Maria was a very deadly storm, one that affected the entire island but hit the poor and the elderly the hardest. We are confident that the number - 2,975 - is the most accurate and unbiased estimate of excess mortality to date,” the Milken Institute School of Public Health at the George Washington University, which was commissioned by Rossello to conduct the study, said a statement Thursday.

Despite Trump’s claim that “the Democrats” were behind the increased death toll, the school added that its study was “carried out with complete independence and freedom from any kind of interference.”

Taking into account population loss from evacuations and emigration, researchers calculated the number of deaths that would normally occur during that six-month period. They then compared that against all deaths that did occur, concluding there were nearly 3,000 excess deaths. Particularly elevated risk of death was observed in low income areas and among older males.

“Using a state-of-the-art mathematical model, the team compared the total number of deaths during that time to the expected number based on historical patterns as well as age, sex, socioeconomic status and migration from the island,” the school said.

Focusing on excess deaths is a reliable alternative to trying to ascertain the exact cause of each individual death, according to Jeffrey Howard, a professor at the University of Texas at San Antonio, who co-authored a separate research letter on Hurricane Maria deaths using similar methods.

“Excess deaths reflect the difference between the total deaths observed in a period following the event versus what would have been expected if the event did not occur, and should be interpreted as an estimate of the deaths that likely resulted from the event, both direct and indirect,” he said.

Trump’s tweets generated immediate outrage from Democrats and some Florida Republicans.

“No one says you killed them. But you run government. & government didn’t help them (water is sitting on a g******ed runway). So YOU failed them. This job is more than Rose Garden YouTube posts. People are counting on you to get it right. #HurricaneFlorence is coming. Get focused,” tweeted Rep. Eric Swalwell, D-Calif.

“What kind of mind twists that statistic into 'Oh, fake news is trying to hurt my image.' How can you be so self-centered and try to distort the truth so much? It’s mind boggling,” said Rep. Ileana Ros-Lehtinen, R-Fla.

Others in the GOP shrugged off the president’s baseless allegation or suggested he had a point about the increase in the death estimate.

"I'd like to know why that is and I think the president is in a position to find out," Sen. Chuck Grassley, R-Iowa, told reporters.

Democrats have long demanded an investigation of the federal response to Hurricane Maria like the probe conducted after Hurricane Katrina in 2005. In a report last week, House Oversight Committee Democrats accused Republicans of trying to “insulate President Trump and his aides from scrutiny” by rejecting those calls.

The president is correct that the original official tally of deaths was in the low double-digits, but even the Puerto Rican government acknowledges it was also wildly inaccurate.

"If you listen to all of our communications, mine in particular, every time we spoke about the death toll numbers in the early going after the storm, we always knew that that number was going to be much higher. We just needed to have a real, better mechanism for identifying," Rossello told CBS News Thursday.

When President Trump visited Puerto Rico soon after the storm, the official death toll was only 16. He remarked at the time that Maria was not “a real catastrophe like Katrina,” the 2005 hurricane that resulted in more than 1,000 deaths in Louisiana and surrounding states.

“Sixteen people certified. Sixteen people versus in the thousands,” Trump told local officials. “You can be very proud of all of your people and all of our people working together. Sixteen versus literally thousands of people. You can be very proud. Everyone around this table and everyone watching can be very proud of what's taking place in Puerto Rico.”

The number of dead quickly rose to 34 after that, and it was officially increased to 64 in December. Since then, officials resisted updating the figure until the research commissioned by Gov. Rossello was completed in August.

At the end of August, the Miliken Institute School of Public Health released an initial report estimating 2,975 people died in Puerto Rico as a direct or indirect result of Hurricane Maria between September 2017 and February 2018. Rossello has accepted that as the official death toll, but he acknowledged even that is not final.

“It could be less, it could be more as time passes,” he said.

Determining deaths attributable to a natural disaster is an inherently inexact science. Beyond obvious cases like drowning or people being hit by flying debris, concluding that conditions caused by a storm indirectly contributed to a death can be more subjective.

“I thought it would have been just a matter of counting body bags,” said John Mutter, a professor at Columbia University who attempted to assess the total deaths caused by Hurricane Katrina. “The problem comes when you think about definitions of what is a disaster-related death.”

The Centers for Disease Control and Prevention has published a reference guide for medical examiners to classify deaths as directly or indirectly related to a natural disaster. Those guidelines were first developed in the late 1990s, but due to a lack of awareness, the CDC has found disaster-related deaths continued to be under-reported.

“What makes this difficult is that following a natural disaster or mass casualty event like this, there is a lot of chaos,” Howard said. “There is a lot of damage to buildings, roadways, downed power lines. It’s often dark and so forth. The initial response is focused on rescuing survivors, not necessarily on systematically defining how deceased individuals died. As days, weeks and months go by, it then becomes very difficult to reconstruct the exact circumstances that impacted each fatality.”

According to the CDC, deaths that are “a consequence of the unsafe or unhealthy conditions created by the hazard or event, or by preparations for or cleanup after the natural hazard or event, or by performing work to minimize consequences of the disaster” should be recorded as disaster-related on the death certificate. This includes deaths that occur during evacuation or that are caused by a loss or disruption of health care, utilities, or transportation, even if they happen months or years later.

“We don’t count people who would have died anyway,” Mutter said. “The rule is: had that hurricane not happened, would that person still be alive?”

In theory, GW researchers could have collected all the death certificates issued after Hurricane Maria and counted the ones that were marked disaster-related. However, when they interviewed medical examiners in Puerto Rico, they discovered many either did not know about or understand the CDC guidelines or were reluctant to follow them due to concerns about subjectivity and liability.

Other efforts to calculate the number of deaths caused by the storm have resulted in different estimates, but all were many orders of magnitude higher than the original official figures.

Reporters meeting residents in communities across the island quickly saw evidence that more than a few dozen deaths had resulted from the storm. In October, BuzzFeed reported nearly 1,000 bodies were being cremated by funeral homes without determining if they were linked to the hurricane.

In November, CNN contacted about half of the funeral homes on the island and discovered 499 deaths that funeral directors considered hurricane-related. The following month, The New York Times estimated there were 1,052 excess deaths between September and December.

An independent analysis released by demographers in November 2017 estimated 1,085 more deaths after the storm than expected. In February, a statistician at the University of Puerto Rico estimated 605 to 1,039 people died due to Maria in the six weeks after the storm.

Another academic analysis published in May provided an extremely wide range of 793 to 8,498 deaths. The midpoint of 4,645 deaths was seized upon by critics of the government response, but the study said that was no more likely than any other number in that broad range.

Research published by Jeffrey Howard and Alexis Santos-Lozada of Penn State University in JAMA in August linked between 1,006 and 1,272 deaths to the storm. In an official report to Congress, the Puerto Rican government estimated 1,427 more deaths occurred in the four months after the storm than would be considered normal, taking a similar approach to the George Washington researchers.

“There are multiple methodologies to assess this, and that is why there has been many different estimates of the number of deaths,” Howard said.

Mutter, who advised The New York Times on its estimate, said it was clear to disaster experts from the very beginning that the government was underestimating the death toll.

“Everybody rolled their eyes and said it can’t be that low,” he said.

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