Preparedness

Who Decides That a Death Was Caused by Hurricane Florence? And Why Does It Matter?

The death toll is an important way of measuring the magnitude of a storm like Florence.

by Richard Stradling, The News & Observer (Raleigh, N.C.) / October 9, 2018
Areas of Kinston, N.C., remained under water late Friday, Sept. 21, 2018, as a result of Hurricane Florence. More than two weeks after Florence came ashore along the coast of North Carolina, the death toll from the storm continues to rise. TNS

(TNS) — Both men died when they fell — one from a ladder, the other from a roof — while they were cleaning up after Hurricane Florence even as the storm was still causing rivers to rise in Eastern North Carolina.

Gov. Roy Cooper announced last Tuesday that they were the 38th and 39th people in North Carolina to lose their lives as a result of the storm. It had taken 10 days for the two men to officially be added to the storm’s death toll.

The lag time illustrates how difficult it can be to fully account for the number of deaths caused by a natural disaster as large and widespread as a hurricane. That they were added to the list at all shows how important that full accounting is.

The death toll is an important way of measuring the magnitude of a storm like Florence; at each one of his daily briefings after the hurricane, Cooper always provided the latest number. But emergency managers say the most meaningful information is how those people died.

“That then starts to place emphasis on how you might prevent deaths in the future,” said Elizabeth Frankenberg, a sociology professor at UNC Chapel Hill and director of the Carolina Population Center. “What kind of warning systems do you need and how much time do you need to give people?”

Mike Landry, a physical therapist on the faculty at Duke University, has responded to natural disasters with various aid groups throughout the world, including Haiti, Sri Lanka and Nepal. Landry says United Nations training exercises stress the importance of gathering data on deaths to help emergency managers and responders learn from them.

“We’ll make mistakes,” Landry said. “We just don’t want to make the same ones.”

Hurricane Florence provided a good example of the wisdom learned from how people died in past storms. During Hurricane Floyd in 1999, nearly half of the 51 people thought to have died in the storm in North Carolina drowned when their car or truck was swept away in floodwaters. After Hurricane Mathew two years ago, 17 of 26 people died this way.

With Florence, whenever Cooper or other state officials spoke about the storm, they admonished people not to drive on flooded roads and to heed signs and barriers. (The National Weather Service has even trademarked the slogan “Turn around don’t drown.”) The message may have gotten through to some: Of the 40 deaths attributed to Florence so far, only 10 were people who drowned after their car or truck went in the water.

More deadly?


Hurricane Florence is the first major storm to hit the Carolinas since the federal government published a reference guide for counting deaths after a natural disaster last fall. The Centers for Disease Control and Prevention said it was trying to eliminate “inconsistencies” that made it difficult to produce reliable and accurate information about how many people died and how.

The guidelines say those deaths break down into two categories: Direct and indirect. If someone drowns or is hit by a fallen tree, that’s considered a direct result of the storm.

Indirect deaths occur because of unsafe or unhealthy conditions at any phase of the disaster, including preparation and cleanup. These may not initially be seen as related to the storm and may take longer to count. There’s also an element of judgment and making connections that some may not see initially.

“If you’re killed in the storm itself or in a way that’s directly connected to preparation or recovery efforts, that makes it clear that it’s related to the storm,” Frankenberg said. “But if your heart condition is aggravated by worry about the storm, that’s harder to attribute.”

Among the indirect deaths blamed on Hurricane Florence is an 81-year-old man who fell and struck his head while packing to evacuate his home in Wayne County.

The final decision about whether someone’s death was caused by the storm rests with the Office of the Chief Medical Examiner in Raleigh. The office said it could not provide a staff member to be interviewed for this article, but did answer several written questions about how death data is compiled.

“The death of someone who fell and struck their head while packing for reasons other than an evacuation would not be considered a storm-related death,” the medical examiner’s office wrote. “But for the storm, the death likely would not have occurred at that time, place and for that cause.”

Reports of suspected storm-related deaths come in to the Chief Medical Examiners Office from either county medical examiners or from the State Emergency Operations Center, which gathers information from law enforcement and other local agencies.

Delays are understandable, according to the medical examiners office. Death investigations can take time, particularly when an autopsy is needed.

“And when the circumstances and cause of death is not apparent, it could take days or weeks to make a final determination,” the medical examiners office wrote. “Medical providers may not realize a death is storm-related. This is especially true in indirectly related deaths.”

Some or all of those indirect deaths may not have even been counted in past storms. None of the 51 deaths attributed to Hurricane Floyd occurred during cleanup after the storm, like the two men added to the list for Hurricane Florence last week. The medical examiners office says it’s possible that the broader definition of a storm-related death in the federal government’s guidelines could help explain the higher toll from Hurricane Florence compared to Matthew.

Final number?

The medical examiners office says there’s no cut-off point for determining a storm’s death toll; on Monday, a death that had occurred Sept. 20 was added to the list.

But in reality the numbers usually don’t change after a month or two. Indirect deaths that may result from long-term problems, such as lack of power or access to medications or health care or the cumulative effect of exposure to mold or other toxins after a storm, often go uncounted.

Researchers at George Washington University tried to get at that impact after Hurricane Maria in Puerto Rico through a process that resulted in a number criticized as politically motivated by President Trump.

The researchers looked at death rates in Puerto Rico for several years and used them to extrapolate what the number would likely be for the six months after the storm. They then compared that to the actual number of deaths to come up with an estimate of “excess mortality” due to the hurricane.

Their number of 2,975 was well above the Puerto Rican government’s official toll of 64, a number that was criticized for months as too low. Trump tweeted that the estimate of nearly 3,000 deaths was ginned up by Democrats to make him look bad, but the George Washington researchers defended their work as “the most accurate and unbiased estimate of excess mortality to date.”

Frankenberg, the director of the Carolina Population Center, says the excess mortality number alone may not provide specific lessons for preventing deaths in future storms; for that, you’d need to dig deeper into death certificates and other data to learn how people died and what factors may have contributed.

But she said such studies can be helpful in realizing a storm’s true impact.

“It could be routinely done,” she said. “And my guess is that somebody will do it for North Carolina.”

For people whose deaths are officially linked to Hurricane Florence, their families could qualify for help with burial expenses from the Federal Emergency Management Agency. It would be something to note when they are registering for FEMA aid, said agency spokesman Mike Wade.

But there’s really no financial benefit to state or local governments for having a higher death toll, Wade said. FEMA’s decisions about assistance after a storm are based on several factors, including damage to housing and businesses, he said.

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