Arecibo, Puerto Rico (CNN) - Cross Platform Link: Versión en español
You won't hear about her death from officials investigating the aftermath of Hurricane Maria, but you should know her name and her story.
She was Isabel Rivera González.
Rivera was 80. She loved to dance, and was known in this hilly enclave of Puerto Rico for her Saturday-night merengue moves. In family photos displayed at her funeral last week, she was shown laughing near a shoreline as flamingos tiptoed behind her. In a black-and-white image, she beamed as she held an infant, one of her five children. Those children described their mother as healthy and full of energy late into her years -- a woman who lit up a room.
Rivera survived Hurricane Maria on September 20 huddled next to her boyfriend, Demencio Olmeda, 76. The storm's winds tore out their curtains and windows, swirling debris in the sky, knocking out power and water service and killing, officially, 51 people.
"I will remember her every day," Olmeda told me.
On October 15, three weeks after the storm, Rivera died awaiting a procedure at a hospital that had lost power in the hurricane and whose backup generator failed, according to several of her family members. Such deaths -- those of people who might be alive if not for the storm -- should be analyzed as part of the US territory's efforts to tally hurricane mortality, said Héctor Pesquera, secretary of Puerto Rico's Department of Public Safety, which oversees the count.
Yet Rivera's death was not assessed or counted in connection with Hurricane Maria's death toll, CNN learned after interviewing Puerto Rican and federal officials, as well as funeral home directors and hospital administrators in Rivera's municipality, Arecibo, located about an hour west of San Juan, the capital.
The official hurricane death toll for Arecibo stands at one -- a landslide fatality that was autopsied at the Bureau of Forensic Sciences in San Juan, according to government documents. Rivera did not die in a landslide and her body was not sent to San Juan for an autopsy, according to family members and Roberto Jiménez, her funeral home director.
"I view her death as a direct result of what happened" because of the hurricane, said Christina Camacho, one of Isabel Rivera's grandchildren, who lives in Philadelphia.
The hospital where she died disputes that claim.
Rivera's story -- and that of her municipality -- is the start of a CNN examination of uncounted deaths following Hurricane Maria in Puerto Rico. If you know someone who died during the hurricane or its aftermath and may have been uncounted by the government, please consider filling out our online form in the story below. You also can message CNN on WhatsApp at +1-347-322-0415. We aim to investigate some of your stories as a way to determine whether deaths are being undercounted.
'The numbers just don't add up'
All hurricane-related deaths in Puerto Rico must be reviewed by the Bureau of Forensic Sciences, according to Pesquera. Interviews with funeral home directors, however, suggest some bodies of people who may have died of causes related to the storm never make it.
To get a sense of how many deaths may have been uncounted by the government, I decided to conduct an informal experiment: Between October 19 and 21, I visited all five operational funeral homes in Arecibo, which is one of Puerto Rico's 78 municipalities, home to about 88,000 of the territory's 3.4 million people. Two additional funeral homes were closed.
I met Rivera's family on this search, along with Jiménez, the funeral home director.
Jiménez, who operates the Cristo Rey funeral home in Arecibo, told me he'd recorded 39 deaths since Hurricane Maria, up about 15 from the same timeframe in previous years.
Some of that increase may come from the fact that two funeral homes in the area are closed, he said. But he suspects four or five of the deaths were hurricane-related.
In total, Arecibo funeral home directors counted 114 deaths in the month since the storm. About 25 seemed likely related to Hurricane Maria, they said, based on their conversations with relatives. Roughly 20 of those bodies were sent to San Juan for forensic analysis, they said.
One of the largest hospitals in Arecibo, Hospital Pavia, declined to comment for this story. On October 5, hospital officials told NPR that 49 bodies had been taken there since the storm, likely including some from neighboring municipalities. José J. Martínez, who owns Funeraria San Luis, down the street, told me he visited the hospital shortly after the storm. Bodies were piled on top of one another in the morgue, which was clearly beyond capacity, he said.
"The vast majority of the bodies were decomposed," he said. "It was a horrendous smell."
José S. Rosado, executive director of Manatí Medical Center, where Rivera died, told me that no deaths from that hospital had been sent to San Juan for forensic analysis. Only blunt trauma, drownings, falls, crime scene victims and bodies that are found dead on arrival should be sent to the capital for analysis, he said. That conflicts with instructions Pesquera told me were distributed to all hospitals in Puerto Rico, which he said included indirect causes of death.
"They were all natural causes of death," Rosado said.
Separately, 112 people are reported missing in Puerto Rico since the hurricane, as of October 18, said José Rosario, the police sergeant handling missing persons reports.
It's unclear if and whether some of those people will be listed as having died in the hurricane, said Pesquera. There's no deadline on that process, he said, and families, funeral homes or hospitals could dispute how a death has been classified even after the person is buried.
As of October 21, the Bureau of Forensic Sciences had analyzed more than 750 bodies, Pesquera told me. Of those, 51 deaths have been found to be hurricane-related, including two more recent deaths connected to waterborne illness, which the government confirmed this week.
Sixty-three bodies were backlogged and awaiting autopsy in San Juan, he said.
It is improbable the official hurricane death toll is high enough, said Martínez, the funeral home owner. His funeral home processed 12 bodies in the month after the storm, he said.
"I suspect most of them were probably from the hurricane," Martínez told me. He cited an example of a woman who died of an apparent heart attack while waiting in line for fuel.
"The numbers just don't add up."
'We took her home all right'
Some particulars of Rivera's death are in dispute.
Manatí Medical Center confirmed the power outage to me but said a pre-existing heart condition led to Rivera's death, not the outage. "She was too unstable to undergo that procedure" to remove fluid from her lungs, said Dr. Luis Rosa, the center's medical director.
The hospital also had the ability to perform the procedure with a small emergency generator but elected not to because she had not responded to other treatments, Rosa said. Additionally, Rivera had been to the hospital before the storm with heart-related issues, he said.
Olmeda, Rivera's boyfriend, meanwhile, told me the procedure was postponed because of the power outage. Relatives said the hospital downplayed the seriousness of the situation. Several of them told me she was in relatively good health before the hurricane hit.
"The doctor kept saying by Monday she could go home," said Miguel Cruz, Rivera's son.
"We took her home all right."
It is sometimes difficult, if not impossible, to determine whether deaths like this resulted from the aftermath of a disaster, but physicians should err on the side of including such deaths for analysis as part of the death toll rather than ruling them out, said Dr. Gregory J. Davis, a professor and director of the University of Kentucky's Forensic Pathology Consultation Service.
Davis said medical professionals can have reasonable disagreement on these matters, but they generally should follow what he called the "but-for" rule, meaning "but for the hurricane, do you think that person would have died when they died?" If they "might have lived another day," he said, then their deaths should be classified as hurricane-related.
"If somebody is dying of a long-term illness and you put a gun to their head, the cause of death is still the gunshot wound, not the terminal illness," Davis said.
Manatí Medical Center administrators maintain they saw no hurricane-related deaths after the storm, and they say they followed guidelines from the Centers for Disease Control and Prevention in deciding to classify these deaths as natural rather than hurricane-related.
Indirect hurricane deaths are the most subject to dispute, said Davis, from the University of Kentucky, and therefore the most likely to be subject to political manipulation. These deaths -- which might include someone who had a panic attack after the storm and died, or someone who died from an injury suffered while clearing hurricane debris -- should be classified as attributable to the storm, according to Davis and Puerto Rican officials.
"The politician who is worried about optics, whether he's on the mainland or the island, might say we're not going to include those deaths because that inflates the number," he said.
'Horseshit' that death toll would be manipulated, official says
Some Puerto Ricans find it suspicious that, on October 3, when US President Donald Trump visited the island, the official death toll was listed at only 16 people.
"You can be very proud of all of your people and all of our people working together," President Trump said at the time, refining the relatively low death count. Compared to a "real catastrophe" like Hurricane Katrina, Trump said, "no one has ever seen anything like this."
Shortly after Trump's official visit, the death count jumped to 34.
Tina Cruz, Isabel Rivera's daughter, told me the family feels forgotten by the government.
Pesquera, the head of Puerto Rico's Department of Public Safety, defended the government's efforts to generate an accurate count under extremely trying conditions, in which most lines of communication were cut and many roads on the island were initially impassable.
Any insinuation the count is intentionally kept low is "horseshit," he said.
"You think I care what the government of the United States thinks about the body count? I don't care," Pesquera said. "I could care less what's less embarrassing."
"We work on factual information. Whatever we find that is related or unrelated would be included," he said. "I'd rather include it than not include it. There is no reason whatsoever for us not to include an accurate count. It's the opposite. It's completely the opposite."
When asked about the death toll in Arecibo, specifically, he told me he "can't say if that's fair or not" because he hasn't reviewed the specific cases referenced by funeral home directors.
If Rivera was relatively healthy before the storm -- this is her family's account; the hospital maintains she was a repeat patient with congestive heart failure -- then her death should have been reviewed in case the power outage contributed to her death, Pesquera said.
"Cases where there's doubt, cases where the hospital referred them for autopsy, cases where the district attorney says, 'I think the institute should take care of it,' those we see," he said.
"If I die and the doctor says 'heart attack' but the heart attack is because I did not receive, let's say, for example, oxygen, or I was supposed to go on dialysis, or I had a panic attack during the storm, or some event that can relate to the [hurricane], then you should write it on the death certificate so that we can count it. Those are instructions from CDC [Centers for Disease Control and Prevention]. That's the norm in the States [and was] relayed to all of the hospitals."
'Sometimes it's not known'
In recent weeks, some experts have started to question the veracity of the death toll.
Among the major problems, said John Mutter, a Columbia University professor who studied deaths following Hurricane Katrina, is the fact that all potential hurricane fatalities must be reviewed by a single office in San Juan. Compare that to some -- but not all -- of the 50 US states, which have coroners stationed locally by county or subregion.
"The storm impacted the entire island, not just San Juan," he said.
Communications issues made that situation worse, especially in the immediate aftermath of the storm, said Héctor M. González, director of the Santa Cruz funeral home in Arecibo.
Pesquera, the government official, places much of the responsibility for the count with hospitals. Perhaps, he said, the government should consider requiring doctors to follow certain criteria when assessing which deaths are sent to San Juan for an autopsy following a hurricane.
"I'm telling you that depending on the day we have different flavors" in terms of which deaths are marked as natural and which are forwarded for review, he said.
Hospitals facing power outages have to make life-or-death decisions about who they can and should treat first, said Davis, the professor from the University of Kentucky. "You do have to make those triage decisions that are really tough in those situations. ... These are agonizing decisions. The pit of my stomach churns just having this conversation," he said.
It's unclear exactly whether or how much undercounting is taking place. González, from the Santa Cruz funeral home, told me he did not think the death rate had risen appreciably.
Other funeral home directors in that municipality did suspect an increase.
Mutter, the Columbia professor, told me he would have expected the death toll in Puerto Rico to be in the hundreds -- in part because of the level of poverty on the island, and also because so few people would have been able to evacuate, as they did for Hurricane Irma in Florida.
The death toll is important, he said, because it influences how much money people donate toward disaster relief and it also affects how governments respond.
He acknowledged there always will be uncertainty surrounding some deaths.
"Sometimes it's not known," he said. "They just don't know. The person died on that day and they can't find out what the cause of death was -- so there's a question mark."
Other deaths can be investigated by interviewing family members or conducting a forensic analysis. But once a body is buried, Mutter said, much of the evidence is inaccessible.
'In the house of the Lord forever'
On October 20, Isabel Rivera González's relatives opened umbrellas to shade themselves from the Caribbean sun as they prepared to lower her body into a tomb that's yet to bear her name.
Christina Camacho, Rivera's granddaughter, pressed her forehead onto the casket and wailed in agony. She threw a single white rose into the tomb before the body was lowered into the Earth and then covered with cement. Sweat speckling her brow, Camacho and others heaved a granite lid on top of that, rolling it into position with the help of rusty metal pipes.
A pastor read Psalm 23 from the Bible in Spanish.
Yea, though I walk through the valley of the shadow of death, I will fear no evil: for thou art with me; thy rod and thy staff they comfort me ... and I will dwell in the house of the Lord forever.
After the burial, a few family members gathered by another tomb uphill from Rivera's. I walked over to talk with them, crossing through some of the wreckage the hurricane created -- stone crosses toppled by winds, a decapitated statue of Jesus. In the distance, trees that had been stripped of their leaves were showing tufts of green -- small signs of renewal on an otherwise battered island.
By the second gravesite, I found Rodolfo Rivera, 63. The tomb was his mother's: Mercedes Rivera Areas, Isabel's sister-in-law. She died of heart failure about a week after the storm, at 85, he said -- a second death in one family in the aftermath of Hurricane Maria.
The sisters-in-law were close, Rodolfo Rivera told me. Isabel was one of 24 siblings. In the 1950s, when Isabel's brother and Mercedes started making a family of their own in Ohio, Isabel moved there from Puerto Rico to help them raise their children. There, she met her late husband. The two couples all shared a house, he said, like one big family.
Rodolfo Rivera believes the stress of the storm led to Mercedes Rivera's death, too.
"She'd still be alive if it wasn't for that hurricane," he said.
Now that she and Isabel have been buried, the family -- and Puerto Rico -- may never know.