Fighting for those who can no longer speak

IN EARLY June, activists in San Juan initiated Proyecto 4645 — a call for people to bring shoes to the marble plaza in front of the Capitol building to memorialize those who died as a result of Hurricane María.

In about one week, 2,888 pairs of shoes were brought to the plaza to remember victims of the disaster. That was more than 45 times the official death toll that the government claimed for most of the time since last September.

Thousands of people came to the plaza — in tears, praying, comforting each other — to mourn loved ones and share their stories. Most of the shoes left on the plaza were actually worn by the deceased. One son came to memorialize his father, and since he had already parted with his father’s shoes, he took off his own, left them as a tribute, and walked away barefoot.

Another handwritten note left at the plaza read: “Papi, I bought you a brand new pair of shoes, since you were barefoot when you left us.”

Project organizers numbered each pair of shoes and took a picture of them, labeled with the person’s name. In many cases, the photos also include signs, flags, flowers, plants, heartbreaking notes and other mementos.

One of the main organizers, Rafael Acevedo, explained that Proyecto 4645 was meant to be:

an expression of our collective pain — an opportunity for us to feel our pain, and to fight, and pay our respects to and honor the lives of our dead...

What ended up happening was an outpouring of humanity and a gathering of solidarity. We heard tens of love stories. We paired names to the numbers. We paid our respects with dignity. We appreciated a healing silence, an exercise in remembering. We needed it. We still need it. We occupied a public space, because not only was the state inefficient in their response, they were negligent and completely incapable of giving us the space and time that we needed to reflect.

PROYECTO 4645 — which will be relocated outside the center of San Juan so the memorial can continue to collect and record stories of the dead — is stark testimony to the accuracy of a Harvard University study released at the end of May, which provided hard evidence for what Puerto Ricans have been saying for months: That official government figures for Hurricane María deaths were a gross misrepresentation.

For months, the official number of dead was frozen at 64 hurricane-related deaths, but the Harvard study estimated that between September 20, 2017 and the end of last year, there were an excess of 4,645 deaths in Puerto Rico as a consequence of the hurricane disaster.

The Harvard study was an embarrassment to the government, but it was no surprise to those familiar from personal experience with the level of devastation and neglect that Puerto Rico was subjected to after Hurricanes Irma and María.

In just a matter of a week, Proyecto 4645 started filling in the details behind the Harvard study’s statistics. Together, they tell the story of neglect and impoverishment — and illustrate the consequences of a hospital and medical system in shambles, weeks and months without electricity, and an infrastructure and society that, to this day, remains in a state of precarity.

Some of the photos left at the plaza were of those who died because they needed electricity to live, and were left vulnerable when the already ramshackle electrical grid broke down after the hurricane. Other photos pay tribute to people who couldn’t access needed health care because of lack of medicine or transportation.

A pair of grey slippers, labeled number 2,355, carried a hand-scrawled note that included: “#Renal #Dialysis #Oxygen.” A pair of sneakers came with a note that read: “Grandma was taken away with the flowers by Hurricane María” — a reference to the way that high winds from the storm tore the flowers and leaves off many plants and trees.

Another pair of shoes carried a note: “For the 96 people who took their own lives from October to December in Puerto Rico.” Another pair is dedicated to the premature babies who died, “unable to breath, without enough oxygen.”

The last pair of shoes collected on the Capitol plaza, number 2,888, was brought by the grandson of a man from Bayamón. “They didn’t have electricity,” read the note that came with the shoes, “so when they requested a refill of his oxygen supply, it never came.”

The project was an expression of collective mourning, but also of frustration and anger at a government that has done little to even acknowledge the level of devastation in the weeks and months after the hurricane — an act, as another organizer, Gloribel Delgado, told Univision, “of remembrance.”

SINCE DECEMBER, the Centro de Periodismo Investigativo (Center for Investigative Journalism) of Puerto Rico has been collecting the stories of María-related deaths in Puerto Rico through its #QueCuenten campaign.

In early June, the Center won a court decision ordering the Roselló administration to release to the media statistics related to María deaths — the full information had been concealed for months.

As a result, the Puerto Rico Department of Health published new “official” statistics that put the death toll from September to December of last year at 1,400 higher than in the same period in 2016.

But this is still a fraction of the estimate made by Harvard researchers.

The Harvard team’s statistics are undeniable. It conducted its survey in January and February 2018 after dividing Puerto Rico into eight regions, classified according to their “remoteness,” or the travel time for their residents to reach an urban area of 50,000 or more people.

Thirteen barrios, or administrative units, were chosen from each region, and interviewers — mostly graduate students from Carlos Albizu University and from Ponce Health Sciences University — interviewed members of more than 3,000 households.

Interviewers asked household members to tell them if anyone in their household had died in 2017, to what did they attribute the death, if they knew of other households within a five-minute walk of their residence whose family members had died, whether anyone in their household had moved, and an estimate of the amount of time after Hurricane María to the end of 2017 when they were without water, electricity and cell phone service.

Not surprisingly, the researchers found that the remoter the location, the greater the number of days without water, electricity or cell service.

In the most remote barrios, 83 percent of households were without electricity for the entire time from when the hurricane hit to the end of 2017. On average, households went 84 days without electricity, 68 days without water and 41 days without cell service, according to the New England Journal of Medicine.

Based on the interviews, researchers calculated that in the period between September 20, 2017, when María hit, and December 31, 2017, 14.3 per 1,000 people died, compared to 8.8 per 1,000 during the same period in 2016. This 62 percent increase in the death rate worked out across the island to 4,645 more people who died during the period in 2017.

“Excess deaths” is a standard method that epidemiologists use to calculate the impact of catastrophes, from natural disasters to famines to wars. It was the method that the prestigious British medical journal The Lancet used to estimate the death toll from the U.S. invasion of Iraq — despite the Pentagon’s efforts to discredit the study.

The estimate of 4,645 was actually the most conservative number that the Harvard researchers calculated. This was because the death rate reported in one-person households was zero, for obvious reasons. The researchers proposed methods to adjust for this “survivor bias,” estimating death tolls of at least 5,045 or even as high as 5,740.

These figures aren’t without their critics, and not just from shills for the government. The Harvard researchers themselves reported that their estimate of 4,645 deaths had a substantial margin of error: it could have been as low as 783 or as high as 8,498. Media and other studies have estimated hurricane-related deaths at between 1,000 and 2,000, and the Roselló government has contracted with researchers from George Washington University for another study.

Whatever figure is closer to the “true” death toll, though, all of these is many times more than the absurdly low former official estimate of 64 deaths.

The story of the death of a baby born after 25 weeks, reported in the New York Times last December, tells us what all these numbers mean on a human level.

The baby, Isaías, was born before Hurricane Maria. His condition had stabilized in the hospital, but it declined after the hurricane, when the hospital lost power and had to rely on generators. As Isaías father told the Times, “He got some kind of bacteria. Everything that started happening to him happened after the hurricane.”

The Times continued: “Isaías died on October 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.”

In other words, official statistics say Isaías died of a number of conditions that appear to have nothing to do with hurricane María. Yet it’s likely that Isaías would have survived had the hurricane not plunged the hospital into crisis.

The Harvard study corroborated the conclusion that disruption to the health care infrastructure was a chief cause of death in the aftermath of Hurricane María. “Approximately one third of post-hurricane deaths were reported by household members as being caused by delayed or prevented access to medical care,” reads the report.

Many of these disruptions could have been prevented, or at least reduced, if the Puerto Rican government had an emergency plan for the health system. Despite spending $33 million in federal funds dedicated to developing a system-wide emergency plan since 2009, the Puerto Rican Department of Health didn’t manage to accomplish this, according to the Center for Investigative Journalism.

The health system — largely privatized in the 1990s under a government that either couldn’t, or wasn’t interested in regulating, the hospitals it licensed — reacted to the hurricane in a chaotic and uncoordinated way.

Those who are bringing the shoes and stories of loved ones to Proyecto 4645 refuse to accept this state of affairs as “routine” or “normal.” As Mariny Vasquez put it in an emotional and stirring Facebook Live video at the installation on June 3:

I am here because my shoes need to stay full and no more shoes should be emptied. No one else should die because of Hurricane Maria. Because now the hurricane is called poverty. Now the hurricane is called despair. Now the hurricane is called abandonment. Now the hurricane is called cheap politics.

But there has also been a lot of healing, as people here have done. Healing in Puerto Rico is called solidarity. It is called resilience. It is called collaboration. It is called mutual aid groups. It is called brigades, missions. Not one more empty shoe on our island!