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What Hurricane Maria’s Death Toll Reveals About Health Care in Puerto Rico


Published June 7, 2018, in the Harvard Business Review. Reposted with permission.

An estimated 1,833 lives were lost in 2005 in Hurricane Katrina, one of the deadliest storms in U.S. history. The federal government’s lack of preparedness and inadequate response to Katrina met with widespread criticism, and the need for a more robust system to respond to natural catastrophes emerged as one of the key lessons from the 2005 storm. The impact of Hurricane Maria on Puerto Rico indicates that these lessons have not been learned: The storm, which hit the island last September, rendered tens of thousands of Puerto Ricans homeless, left over a million people without electricity for several weeks, and caused an estimated $90 billion in damages (making it the third-costliest tropical cyclone in the United States since 1900).

A study published in the New England Journal of Medicine on May 29 estimates that the death toll associated with Hurricane Maria in Puerto Rico is at least 4,654, over 70 times the original official count of 64. (Last Friday, the Puerto Rico Department of Health raised its own estimate by at least 1,400, which is still far below the estimate in the study.) The mortality rate in the immediate aftermath of the storm (September 20 through December 31, 2017) was 14.3 per 1,000 persons, a 62% increase from the official rate for the same period in 2016, researchers from the Harvard T. H. Chan School of Public Health and other institutions found. The “interruption of medical care was the primary cause of sustained high mortality rates in the months after the hurricane,” the researchers wrote.

There are three explanations for why so many people died after Hurricane Maria: the anemic response of the Federal Emergency Management Agency (FEMA), the relatively poor health of Puerto Ricans before the storm, and the weak infrastructure and paucity of funding of the health system prior to Maria striking the island. It is especially important to note that because modern medicine can sustain individuals with chronic illness who previously would have succumbed to their conditions, the failure of a local health care system may be particularly threatening to the post-disaster health of the affected population. These explanations are related to the differential treatment Puerto Rico receives because it is a territory, not a state; and although its residents are American citizens, they do not enjoy the same rights as their counterparts on the mainland.

FEMA’s Response to Hurricane Maria

Three particularly large storms made landfall in the United States in the 2017 hurricane season: Hurricane Maria hit Puerto Rico shortly after Hurricanes Harvey and Irma caused widespread damage in Texas and Florida, respectively. FEMA had its hands full coordinating responses to all three disasters, at times simultaneously, but the vast discrepancy between the aid to Texas and Florida on one hand and Puerto Rico on the other shows that the destruction from Hurricane Maria was not treated with the urgency and gravity it deserved. The numbers tell a sobering tale: FEMA delivered 2.8 million liters of water in Puerto Rico within nine days after Maria made landfall, while it delivered 4.5 million liters in Texas after Harvey and 7 million in Florida after Irma. Given that Maria left over half a million homes roofless, there was a dire need for tarps in the immediate aftermath of the storm. But FEMA delivered only 5,000 tarps to the island, compared with 20,000 in Texas and almost 100,000 in Florida.

FEMA also deployed fewer personnel to Puerto Rico (10,000 compared with 30,000 deployed after Harvey and 22,000 after Irma). It provided $2,974 housing assistance on average to those impacted by Maria, while housing assistance to those impacted by Harvey was more than double, $6,980. The average Puerto Rican is much poorer than the average American, with a median household income of $20,078 compared with a national average of $57,617, implying that there was an acute, unmet need for disaster-related financial assistance.

Federal officials caution against comparisons between storms, arguing that the geographic, financial, and political situations of Puerto Rico and Texas are vastly different. But these numbers help illustrate how severely under-resourced Puerto Rico was in the immediate aftermath of the storm. This lack of resources likely compounded the effect of the considerable disruptions to medical services and health care delivery that the study published in the New England Journal of Medicine reported.

Puerto Ricans Were More Vulnerable to Start With

Even before the storm, Puerto Rican adults were less healthy than Americans on the mainland. They receive less preventive care: Fewer Puerto Ricans received recommended cancer screenings, vaccines, and immunizations than counterparts on the mainland.

Puerto Ricans are also more likely to report greater health needs, with 34% reporting “fair or poor” general health, as opposed to 18%, on average, nationally. These existing vulnerabilities likely exacerbated the injury, illness, or loss of necessary medical services directly attributable to Hurricane Maria.

The Health System Was Frail Even Before the Storm

Puerto Rico faced a $72 billion debt and multiple funding challenges before Hurricane Maria hit. In addition to the health vulnerabilities of the population, Puerto Rico’s health care infrastructure was crumbling, and its public programs were severely underfunded.

Unlike U.S. states, Puerto Rico has not had access to many benefits of the Affordable Care Act (ACA). It has neither a state-run nor a federally-facilitated individual insurance marketplace. Between the inability of individuals to buy subsidized individual health insurance through ACA marketplaces, and its high poverty rate, Puerto Rico relies more on public programs like community health centers, Medicaid, and Medicare. But because it is a territory, it gets less money and resources from the federal government for Medicaid than it would if it were a state.

The bottom line is that when Hurricane Maria hit, Puerto Rico could not meet the emergency, health, and other needs of its population. The inadequacy of FEMA’s response worsened the situation, resulting in the alarmingly high mortality rate.

Lessons to Mitigate Future Hurricanes’ Impact on Health

As Sandro Galea, the dean of Boston University’s School of Public Health, wrote recently, the lessons from Hurricane Maria include a need for communities to be better prepared to handle the full range of health consequences of disasters. Improvements to basic infrastructure and investment in human capital must take place well before hurricanes hit.

Hurricane Maria and other recent catastrophes have shown the need for health systems to become more resilient to climate change-related disasters. Health systems can adapt and build infrastructure that is more resilient to natural disasters to protect their patients and facilities. Houston’s health system was not as adversely affected by Harvey as Puerto Rico’s was by Maria because of lessons learned from a devastating 2001 storm in Texas.

Other related lessons include the necessity for FEMA to be prepared for the upcoming hurricane season and, in the event that a natural disaster strikes, the federal response must be equitable in all parts of the United States. The study published in the New England Journal of Medicine points out that Puerto Rico’s government suppressed the death rates and stopped sharing mortality information with the public in December 2017. Accurately counting deaths is critical if we are to be better prepared for and responsive to future hurricanes.

As Puerto Rico rebuilds its health system, Hurricane Katrina offers one more valuable lesson. After Katrina knocked out much of the health care network in New Orleans, the federal government awarded Louisiana $100 million to restore and expand its safety-net services. An evaluation of the rebuilt health system found that there was an increase in the number of primary care clinics, patient encounters, and number of patients served. Similar targeted federal assistance could help Puerto Rico rebuild, and even improve, its health infrastructure. This could benefit previously underserved Puerto Ricans for generations to come.

Publication Details



David Blumenthal, Former President, The Commonwealth Fund

[email protected]


David Blumenthal and Shanoor Seervai, “What Hurricane Maria’s Death Toll Reveals About Health Care in Puerto Rico,” Harvard Business Review, published online June 7, 2018.