Hurricane Maria made landfall in Puerto Rico on Sept 20,2017, as a high-end category 4 hurricane, only weeksafter the island had been affected by another hurricane.Puerto Rico experienced severe weather associated withthe hurricane, including storm surges and flash flooding.The hurricane severely affected basic infrastructure suchas electricity and water for several months, initiallyleading to a complete collapse of the power grid,affecting all 3·4 million inhabitants.Early reporting on the death toll of the hurricaneby the government and media was confusing andcontradictory, and led to several law suits. Ultimately,Carlos Santos-Burgoa and colleagues were tasked withdetermining the actual death toll of the hurricane, whichthey now report in The Lancet Planetary Health. 1 Beyondpolitical reasons, some of the initial controversy cancertainly be attributed to the methodological difficultiesof determining excess mortality in post-disaster situa-tions of high complexity. Mechanisms and dynamics ofexcess mortality might not be obvious and hence causedifficulty in correctly attributing mortality to the disaster.Additionally, studies on excess mortality need to considerissues such as internal displacement and disaster-relatedmigration, which change population baselines. Santos-Burgoa and colleagues 1 accounted for these factorsand, using all-cause mortality data from the PuertoRico Vital Statistics System, estimated 2975 excessdeaths (95% CI 2658–3290) from September, 2017, toFebruary, 2018. The uneven distribution of those deathsalong socioeconomic and age strata they noted begsfurther investigation. It is important to understandnot only absolute numbers of excess deaths but alsothe mechanisms and dynamics underlying the excessmortality and hence the reasons for the unevendistribution.
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