A report by Frances Robles for the New York Times.
Almost two months after Hurricane Maria tore through Puerto Rico, there were more signs of how unsettled the situation remains here and how grievous the toll of the storm was.
The Federal Emergency Management Agency said that it was finalizing extraordinary plans to fly about 3,000 residents of Puerto Rico still living in shelters to New York and Florida.
“Transportation assistance is something that I don’t think we have done previously,” Will Booher, a FEMA spokesman, said. “But this is unique to what’s going on in Puerto Rico.” The agency said the relief effort was being undertaken at the request of Gov. Ricardo Rosselló.
FEMA regularly finds housing for hurricane victims, often at hotels or motels nearby. But because there is so little available lodging on the island, and no easy way to get people from shelters to safe housing, the agency is arranging charter flights for residents, beginning with those still in shelters.
On Wednesday, Puerto Rico officials, facing increasing questions about the accuracy of the official death toll from the storm, acknowledged for the first time that 472 more people died this September compared with the same month last year. The storm made landfall on Sept. 20. The government’s official death toll is 55.
The numbers confirmed what had been speculated for weeks: After the waters receded and the roads were cleared, people here continued to die at rates far beyond normal.
As temperatures frequently rose above 90 degrees, the lack of power in nursing homes, private houses and hospitals hit the elderly particularly hard. Soaring temperatures accelerated the deaths of people who were already seriously ill. Ambulances could not arrive, medicines ran out and oxygen tanks that ran on electricity were useless, several funeral directors said.
Even with the increase in mortality in the weeks after Hurricane Maria, authorities insisted that the official death toll remained at 55: 20 direct deaths; 31 indirect deaths, such as suicides; and four more from leptospirosis, a waterborne bacterial disease.
The government said it was up to doctors to certify whether other conditions — such as lack of air conditioning or dialysis because of the blackout — contributed to a person’s death. If families believe an error has been made they should file a report, Héctor M. Pesquera, the secretary of public safety, told reporters Wednesday. But the government, he said, would not be influenced by anecdotal reports or suppositions.
“We are not going to question 29,649 doctors who signed all those death certificates,” Mr. Pesquera said, referring to the number of people who died in the past year. “There’s a process, and there’s the law, and we follow the process and the law.”
Mr. Pesquera said doctors were not going to risk their medical licenses by falsifying death certificates. But families across Puerto Rico are skeptical.
“When my son died, the doctor said we had a right to an autopsy but that it would take a long time, and ‘Well, you know how he died,’” said Jorge Malavé, 51, whose 3-month-old baby, Isaías, died after spending his entire short life in the hospital.
Isaías was born at just 25 weeks, but his condition had stabilized, his parents said. The power went out, and the family was not allowed to visit for three days. Later the hospital ran on a generator. The oxygen machines were operating but the air conditioning was not.
“He got some kind of bacteria,” said Mr. Malavé, 51. “Everything that started happening to him happened after the hurricane.”
Isaías died on Oct. 13. His death certificate says he died of respiratory distress syndrome, chronic lung disease, sepsis and extreme prematurity. Sepsis is an infection that occurs most often to people who are hospitalized.
“All the children were getting sick,” said Bethzaida Vázquez, whose premature baby, Nathan, had been beside Isaías in the hospital. “Every time the generator failed, they would move him.”
Ms. Vázquez said that her son’s condition had improved before the storm, but that the mildew in the air from the lack of air conditioning worsened her son’s breathing. He died on Oct. 4.
Ms. Vázquez, who has since moved to Indiana, also believes her son should be included on the list of storm-related deaths.
“They lied about this and they lied about a lot of things,” said Mr. Malavé, who lost his home in Adjuntas to the storm and then lost his job too. “People should know the real number of deaths. I know there were adults and children who died in that hospital. Who knows what happened there for the three days we were not allowed to visit. How about all those people on oxygen tanks and all that?
Experts agree that temperature control is critical in hospital settings, particularly for people who are elderly or seriously ill. In South Florida, eight seniors died in a single day when the air conditioning went out at a nursing home after Hurricane Irma knocked out the power. Several more patients died in the days afterward.
The funeral directors interviewed agreed that the majority of people who they have seen die in recent weeks were very old and some were terminally ill.
“If they were teetering on a cliff, this is the thing that pushed them over,” said Olveen Carrasquillo, who is the head of the internal medicine and geriatrics divisions at the University of Miami Miller School of Medicine. “What for me or you is an uncomfortable night — or in Puerto Rico, an uncomfortable three months — can be really bad for the elderly.”
Victor M. Ramos, president of the Doctors and Surgeons Association in Puerto Rico, said air conditioning was also crucial to keeping bacteria at bay.
“High temperatures promote certain bacterias; that’s why you need to keep the hospital at a certain level,” Dr. Ramos said. “What’s difficult here is that if you had someone who was critically ill and they died after the hurricane, did he die of the condition, or did he die because there was no power? It’s not so easy.”
Dr. Ramos said the government needed to do a better job of explaining the anomalies and the high number of cremations — more than 900 — reported in the past two months.
At the news conference on Wednesday, Wanda Llovet, the director of Puerto Rico’s demographics registry, said more people died in September because so many young people had left the island, leaving Puerto Rico with an aging population.
Her colleagues, though, said that her reasoning was flawed, since the population had dropped and the absolute number of elderly had not increased.
José A. López Rodríguez, a government demographer who spoke at the news conference, said that the spike in deaths was unusual, but that more evidence was needed in order for the registry to include it in Maria’s death toll.
“In reality, it is not normal,” Mr. López said.
Jesús Santiago, who manages the largest funeral home in Ponce, said the deaths were likely to continue rising.
“I think the government is doing this to not alarm the public,” he said. “But it is alarming because there are still people with no light and no water.”
Some critics note an inherent flaw in not casting some skepticism on the judgment of doctors and officials who could be liable for failures that led to some deaths.
Among those who have cited the low death count was President Trump, who praised Puerto Rico for its response, particularly because the official death toll was so low compared to disasters such as Hurricane Katrina.
No dates have been set for the first residents to be flown to housing outside the island.
Agency officials said Puerto Rican residents who have applied for the Transitional Sheltering Assistance program commonly used after disasters would be eligible for relocation. But they said their priority was the 3,000 people who are currently living in shelters on the island.
Officials said they did not believe that Gov. Kenneth Mapp of the United States Virgin Islands had made similar requests to have residents there affected by hurricanes relocated to the mainland.