The number of people killed in Puerto Rico amid Hurricane Maria is at least 70 times higher than the official government death toll, according to a study published Tuesday in the New England Journal of Medicine.
Researchers in the United States and Puerto Rico estimated more than 4,645 people were killed as a result of the storm, rather than the 64 people included in the official casualty count.
Authors of the study, titled "Mortality in Puerto Rico after Hurricane Maria," noted their figure is "likely to be conservative," saying the total could actually be in excess of 5,000.
"Our results indicate that the official count of 64 is a substantial underestimate of the true burden of mortality after Hurricane Maria," the authors wrote.
Scientists with the Harvard T.H. Chan School of Public Health and Beth Israel Deaconess Medical Center randomly surveyed 3,299 households across Puerto Rico in early 2018, asking them "about displacement, infrastructure loss, and cause of death" between September 20 and December 31, 2017.
Researchers noted that the Centers for Disease Control and Prevention allows for deaths to be "directly attributed to a tropical cyclone if they are caused by forces related to the event, such as flying debris, or if they are caused by unsafe or unhealthy conditions resulting in injury, illness or loss of necessary medical services."
Hurricane Maria barreled into Puerto Rico as a Category-4 storm in September with winds of up to 155 miles per hour and intense rainfall, prompting flooding in the United States territory. More than eight months later, and the island's recovery efforts — marred by a lack of water, electricity and general services — are ongoing.
Calculating the total number of dead in wake of a natural disaster can be difficult, the researchers said, citing a logistically challenging method for certifying death in San Juan. Every disaster-related death must be confirmed by the Forensic Sciences Institute, which requires that bodies be transported to San Juan or that a medical examiner travel to the municipality to verify the death.
The official death estimate has repeatedly been questioned by locals and experts, many of them blasting officials for their lack of transparency. It prompted the Puerto Rican government to commission and external review of the death registry data.
President Trump in October praised the Puerto Rican and federal government for its response efforts and the low death toll in wake of Hurricane Maria.
"We spent a lot money on Puerto Rico, and that's fine," President Trump said during his first visit to the island following the storm.
At the time, the official death count was only 16.
"Every death is horror, but if you look at a real catastrophe like Katrina, and you look at the tremendous hundreds and hundreds and hundreds of people that died, and you look at what happened here and what is your death count? Sixteen people, versus thousands. You can be very proud. sixteen versus literally thousands of people."
Officials have not provided an updated death count since December 2017.
New York Rep. Nydia Velazquez slammed Trump's October remarks, asking whether the thousands of death now constitute as a "real catastrophe."
"By undercounting the fatalities, the true impact of Maria was concealed. By obscuring this, many were left to believe the Trump Administration's mythology that Puerto Rico was not hit hard by Maria," she said in a follow-up statement. "Now, that we are seeing further evidence of what many of us have long maintained - that Maria was an epic disaster. If these estimates are accurate, they would mean Maria's devastation ranks among the most deadly in history."