NAPHSIS thanks Puerto Rico Vital Records for their assistance with this article, including Wanda Llovet Diaz- Registrar of Puerto Rico and Maria M Juiz- Quality Control Division of Vital Records of Puerto Rico. Much of the preceding was transcribed from Spanish into English and summarized; errors may have occurred.
Hurricane Maria was a natural disaster the scope of which Puerto Rico had not seen for many years. It destroyed bridges, toppled buildings, and brought record flooding. But one of the lesser-known effects of the hurricane was its effect on death registration in Puerto Rico.
Typically, an Electronic Death Registration System (EDRS) is used for death registration. Given Puerto Rico’s limited budget, however, they do not have access to this kind of system. In its place, paper is used. During the disaster, electricity was out for a large part of the island, but given that they use paper to record vital records, they could continue their work. The benefits of paper, however, disappeared once it was time to collect and manage the records.
Across the island, communications were out, power was down, water was out, and there was an immense amount of physical damage to vital records buildings. It proved difficult to gather records because many locations across the island were physically isolated from one another- due to floods or bridges having been destroyed. This proved to be a major obstacle.
Things got so bad, some funeral homes couldn't reach the bodies of the deceased. Wanda Llovet Diaz- Registrar of Puerto Rico states: "There were people who died during the night of the hurricane. Many of those deceased remained for some time in their families' homes since a funeral home was not able to reach them".
Other issues are still present. "Even today, we have offices that are closed because they don't have electricity or water" says Maria M Juiz, Quality Control Division of Vital Records of Puerto Rico.
This disaster has also strongly affected the budget of Puerto Rico vital records. Due to electronic systems being down, payments have not been received for the work they do in many cases, including registering births, deaths, marriages, and divorces. Funds available to Puerto Rico vital records were very low before, and are now even lower.
EDRS During a Natural Disaster
We’ve already touched on one major obstacle in death registration that Puerto Rico Vital Records needed to work around- the lack of an EDRS system. "On one hand, having a paper-based system was a blessing, but at the same time, Puerto Rico could not make its data available as quickly as jurisdictions with Electronic Death Registration systems can." - Wanda
But even a functioning EDRS system will have challenges during a natural disaster- especially if electricity is sporadic at best, as was the case during hurricane Maria. For this reason, it is important to have a strong backup plan in place. Backup plans generally include creating a process to overcome a certain period of time without electricity, but in Puerto Rico's case; electricity, communications, and water were all out at the same time. This should be a warning to all other vital records jurisdictions with EDRS systems- backup plans should be created that foresee having both electricity and communications out for extended periods of time.
Death Registration Challenges
A major challenge faced by Puerto Rico after the disaster was counting the deceased. At a first glance, this might appear an easy task. Gather up the death certificates, and count how many people died due to the hurricane. However, this is quite difficult in execution, due to the Cause of Death section in a death certificate. This section determines if a death is related or not to a natural disaster. During hurricane Maria, medical examiners were able to fill out this section, often with the help of family members, but did not always associate a death with the hurricane when the hurricane may have been the secondary cause of the death.
For example, the hurricane may have cut power to a hospital, which caused a patient’s medical equipment to fail, which caused the patient’s death. On a death certificate, cerebral hypoxia may have been recorded as the sole cause of death. In reality, the death should have been tied to the hurricane. Training is needed for medical examiners to completely and accurately fill out death certificates during natural disasters so that deaths due to the natural disaster- either directly or indirectly- are clear.
During a hurricane especially, recorded causes of death that are directly caused by the natural disaster are few, and recorded causes of death indirectly related to the natural disaster are many. Most deaths were likely caused by a lack of access to medical services and electricity. These types of deaths are notoriously difficult to count and correlate with natural disasters, but training can help improve accuracy.
"[Medical examiners] are those who we need to reach to help understand that more time should be taken in filling out the cause of death section of a death certificate in a comprehensive manner", says Maria Juiz.
"Today, [the Institute of Forensic Science of Puerto Rico] has determined that there are 64 deaths. But the vital records statistics of all the deaths we have registered has shown a marked increase in comparison with other months. We registered over 500 more deaths per month during the hurricane greater than what is typical. The certainty that these deaths are related to the hurricane cannot be offered at this time, given the limitation…of the recorded causes of death not being correlated to the hurricane". - Wanda Llovet
Successes Despite the Challenges
During and after the disaster, Puerto Rico Vital Records used their existing system of paper record management to continue their work. They continued registering both births and deaths. They acquired a backup generator that proved electricity.
From Wanda Llovet; "Disaster notwithstanding, we fulfilled the mission of vital records. We even had the statistics…of how many people had died each day, how many births were registered, during and after the hurricane".
Due to the scope of the damage to the island, many Puerto Ricans fled the country temporarily and went to the United States. But since many of these people did not have passports, the only way they could travel was to have a copy of their birth certificate. Puerto Rico's vital records offices provided these people with their birth certificates in a timely manner- whether or not they had basic services running.
Vital Records Data- Key to Understanding
Vital records data is the best source for understanding the mortality increase a disaster brings. Of course, Puerto Rico vital records is not in charge of verifying if deaths are related or not to a natural disaster, it is not their mandate. The number of related deaths is certified by the Department of Public Safety.
Also, George Washington University is investigating the process of establishing cause of death, and correlating appropriate deaths to a natural disaster, directly or indirectly. It may be that they also analyze the extraneous deaths that could be related to the hurricane, and they would review the death certificates that Puerto Rico vital records registered during the event. Puerto Rico vital records is currently working hard and scanning death certificates to send out. Of course, as stated earlier, if an EDRS system were in place this would not be necessary.
The CDC has given priority to Puerto Rico, and has accepted all records that were painfully collected as quick as possible given the circumstances, and sent.
It will be a long road to recovery for Puerto Rico as well as their vital records agency. But one thing is clear- it is of the utmost importance that Puerto Rico obtains an EDRS system. From Wanda Llovet: "An EDRS system would serve as a tool to establish a robust mortality monitoring system during a natural disaster". NAPHSIS strongly supports Puerto Rico Vital Records in this endeavor.
There are positive signs. One month ago, they began talks with FEMA and the CDC to hopefully find a financial solution, but will need assistance from all quarters. Their goal is to create a strong death registration system that can weather any storm.