Letter to the Hon. Brock Long, FEMA Administrator, and the Hon. Alex Azar, HHS Secretary - Warren, Lawmakers Press FEMA, HHS on Updated Hurricane Death Toll in Puerto Rico

Letter

Dear Administrator Long and Secretary Azar:

We write to follow up on your response to a June 12, 2018, Congressional letter regarding fatalities in Puerto Rico. In particular, we are requesting information about how the Federal government is ensuring that the people of Puerto Rico are given adequate funding and assistance in light of the devastation caused by Hurricane Maria and amid new reports that the true death toll from the hurricane was almost 50 times higher than previous official estimates.

On February 22, 2018, Puerto Rico Governor Ricardo Rosselló announced that the Government of Puerto Rico would commission the George Washington University's Milken Institute School of Public Health to analyze existing records and death certificates and estimate the excess mortality from the time the storm hit on September 20, 2018, through February 2018.[1]

According to the recently released report, there were an estimated 2,975 deaths that resulted from Hurricane Maria in the six-month time period.[2] This new estimate is 46 times larger than the government's official fatality count, which stood at 64 since December 9, 2017.[3] Following the report's release, the Puerto Rican government has officially raised the death count to reflect the report's estimate.[4]

As mentioned in the June 12th letter on this matter,[5] the inability to obtain an accurate accounting of fatalities following a natural disaster that occurred on U.S. soil has real and significant consequences. Compiling an accurate death toll is essential to understanding the true severity of conditions on the ground, identifying potential problems and vulnerabilities (e.g., understanding which populations and areas are at special risk during a disaster, and determining which of a disaster's possible impacts require investment in preparations and mitigation), assessing the quality of disaster response, and setting policy moving forward. These statistics also influence the amount of federal aid requested for pre- and post-disaster mitigation and adaptation plans (such as evacuation location needs[6]), which is of critical importance with this year's hurricane season underway.

A spokesman for the Federal Emergency Management Agency (FEMA) called the claims in the June 12th letter "absurd," adding, "The actual counting of disaster-related fatalities is the responsibility of local jurisdictions, not FEMA…. Our continued focus is on supporting Puerto Rico and disaster survivors through the recovery."[7] But what that response overlooks is that accurately counting disaster-related fatalities is inextricably linked to supporting survivors and establishing resilience and preparedness.

The June 12th letter on this subject also noted that FEMA provides financial assistance for funeral expenses caused by a presidentially declared emergency or major disaster. As noted in the response from Administrator Long, in order to be eligible for this funding an applicant must produce an "official death certificate that clearly indicates the death was attributed to the emergency or disaster, either directly or indirectly, or a signed statement from a state, territorial, tribal, or local government licensed medical official."[8]

In response to the June 12th letter on this matter, Administrator Long wrote that "[a]s of July 30, 2018, FEMA received 2,431 applications for funeral assistance, and determined 75 eligible for" assistance.[9] This means that 97% of applicants for funeral assistance either had been denied or had not received a response. Importantly, the George Washington University study concluded that the Centers for Disease Control and Prevention's (CDC) guidelines, which help ensure that medical certifiers know what constitutes a disaster-related death and how to document it on a death certificate,[10] were not consistently followed.

The study found a lack of awareness, lingering confusion, and concerns around the subjectivity of the determination by physicians and forensic physicians in Puerto Rico. It determined that these problems resulted in a "very small number of those completing death certificates … relat[ing] the deaths to the hurricane."[11] Given that the death toll has officially increased to 2,975, we are concerned that there are many families who either qualified for such assistance and were denied, or are eligible for such assistance but are unable to produce the necessary documentation.

Other public reports also provide reason to be concerned. The morgue at the Puerto Rico Forensic Sciences Institute has been over capacity for months.[12] Cadavers stored in refrigerated trailers in the parking lot of the Puerto Rico Forensic Sciences Institute have emitted foul odors, prompting complaints.[13] Those trailers might not be equipped to withstand the summer heat.[14] Dozens of bodies have reportedly gone unclaimed because of "family or financial reasons,"[15] which raises questions about whether withheld funeral assistance is contributing to corpses remaining uninterred or possibly even causing them to decompose before burial.

To identify how the federal government plans to reflect the higher fatality count in their current disaster mitigation and adaptation plans for the island and provision of funding assistance to Puerto Ricans, we ask that you answer the following questions by September 24, 2018.

Given FEMA's repeated deference to local authorities on questions about fatality counts,[16] and its recent statement that FEMA "is not in a position to judge how many people died from Hurricane Maria,"[17] do FEMA and the Department of Health and Human Services (HHS) acknowledge and accept the official death count of 2,975?
If yes, are FEMA and HHS--in light of the newly revised fatality count--reviewing or planning to review their respective responses to Hurricane Maria to account for how each entity could have better supported Puerto Rico to reduce the number of fatalities?

The Milken Institute study noted that though every social stratum and age group were affected by excess mortality, the risk of death was higher and persistent for populations living in lower socioeconomic development municipalities and males over the age of 65.

Have FEMA and HHS ensured that their pre- and post-disaster mitigation and adaptation plans have kept these high-risk populations in mind?
i. If so, how?

ii. If not, why?

Given the near-certainty that many Puerto Ricans eligible for funeral assistance have not received it, and given the obvious need for many bodies to be claimed for proper burial or cremation, what is FEMA doing to expedite the funeral assistance process?
Administrator Long's response to the June 12th letter said, "Until FEMA contacts all applicants, an accurate number of total applicants eligible for funeral assistance is not available." How long do you expect it to take to contact all applicants?
How many personnel are involved in the process of contacting applicants?
Please provide a summary of how applications were resolved, and how many are still pending.
In light of the fact that few death certificates were properly recorded to reflect that an individual died as a result of the hurricane, will FEMA consider alternate documentation of the deceased from families seeking financial relief for funeral expenses?
Will FEMA reconsider denied applications for families that did not have correctly processed death certificates?

According to your August 14 response, HHS "leads the nation's medical and public health preparedness for, response to, and recovery from disasters and public health emergencies," "collaborates with … partners across the country to improve readiness and response capabilities," and "provides medical care and delivers medical supplies and provides expertise to help communities maintain health care operations."[18]
One of the most important roles of medical professionals in responding to, and recovering from, a disaster is to account for those who have perished. The George Washington University report indicated that the physicians who were given CDC death certificate guidelines by the Puerto Rico Vital Statistics Registry (PRVSR) had "no formal training,"[19] "lingering confusion about the guidelines,"[20] or "expressed reluctance to relate deaths to hurricanes due to concern about the subjectivity of this determination and about liability."[21]

i. Will HHS work with PRVSR to ensure that physicians and forensic physicians have adequate training and understanding of the CDC guidelines?

Would nationwide best practices guidance for quantifying mortality and significant morbidity post-natural disaster better enable HHS to "lead[] the nation's medical and public health preparedness for, response to, and recovery from disasters and public health emergencies" and "collaborate[] with … partners across the country to improve readiness and response capabilities"?

Does FEMA believe it has the authority to provide funding to the Puerto Rico Forensic Sciences Institute to help it manage the backlog of bodies in its facilities?

If yes: has FEMA done so? If not, why not?
Sincerely,

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