***Editor’s Note: Please see the introduction to the Pandemic in Paradise series here.***
A month after Gov. Pedro Pierluisi eliminated the key protection measures related to COVID-19, virus-related deaths in Puerto Rico saw a rebound that nearly reached the level of the highest peak of mortality of the entire pandemic.
The difference was that this time most of the people who died were significantly younger.
As opposed to the first peak of deaths related to the pandemic registered in December 2020 that was associated with older adults — when no one had completed the two doses of vaccines— in August 2021, deaths from COVID-19 among people aged 30 to 59 years-old increased, despite the fact that more than 70% of the population eligible to be vaccinated already had both doses, according to data that the Center for Investigative Journalism (CPI, in Spanish) analyzed. During last year’s peak, 72 people of these ages died compared to 104 during this year’s peak, which represents a 44% increase.
The analysis also reveals that during most of 2020 and 2021, Puerto Rico registered excess deaths, including those that occurred from causes that were not identified as COVID. Among the latter, there is a significant increase in deaths from mental health diseases, substance abuse and conditions of the nervous system linked to memory, such as Alzheimer’s, which, according to the clinical experts interviewed, could be indirect consequences of strong social and economic disruptions caused by the pandemic.
The 30-59 age group accounted for 16% of COVID-19 deaths in December 2020, while in August 2021 it accounted for 35%. To date, August is the month with the highest total number of deaths this year with 296, according to data provided by the Puerto Rico Demographic Registry after a lawsuit filed for access to information. Likewise, the age group of 70 and over accounted for almost two-thirds of COVID-19-related deaths in December 2020. As of August 2021, the number was not even half of that.
The number is still preliminary, given that the Registry takes time to process data and, according to the US Centers for Disease Control and Prevention (CDC), it may be missing up to 60% of the information for the disclosed period. The Demographic Registry provided the CPI with the mortality data from 2015 to August 2021. However, because it is incomplete, the data up to May 2021 were used for this analysis. With this limitation, the Department of Health reported 313 deaths by COVID in the August peak, while in the December 2020 peak — with the full data on hand — the Registry accrued 445 deaths from the virus.
Since Pierluisi took office in January, he eliminated and eased the protection measures and to avoid contagions, including dismantling the municipal tracking system. In July, he ended the required use of masks for those vaccinated and the capacity restriction in closed facilities such as movie theaters, restaurants, and large concert halls.
He also delegated responsibility for the guidelines and recommendations on protection measures to Health Secretary Carlos Mellado. This announcement came as cases of the Delta variant began to spread throughout the United States. At the end of July, upon seeing a spike in cases, the government restored the mandatory use of masks in closed spaces regardless of whether the person is vaccinated or not.
The government of Puerto Rico had imposed new regulations to prevent contagion due to the appearance of the Omicron variant following the guidelines implemented by the United States at the time of publication. Puerto Rico has been a U.S. territory since 1898 and all federal laws are applicable on the island.
Dr. Ángeles Rodríguez, infectologist and former epidemiologist of the State, said the change in the distribution of deaths for the 30-59 age group was “dramatic.” She said the COVID vaccine benefited older adults, since their mortality was reduced during the peak of August 2021. The group that has been impacted the most so far this year is those 40-60 years old.
Analysis of the available data and the experts interviewed were unable to establish a definitive reason for the proportional increase in deaths among younger people during the peak in August of this year.
Meanwhile, deaths among older adults at the post-vaccination peak were reduced by almost 50% compared with the pre-vaccination peak. Despite this, and with deaths among those 60 and older declining in August — and more markedly among those 70 and older— deaths among older adults remained high with 186 deaths in a single month. According to Rafael Irizarry, biostatistician at Harvard University, there are currently 200,000 unvaccinated people over 60.
Carmen Delia Sánchez Salgado, Ombudswoman for the Elderly, said Puerto Rico’s population of older adults exceeds 800,000. Among those who are unvaccinated, there are people who have decided not to be vaccinated, and others who have not been vaccinated due to mobility difficulties or coordination of appointments. The latter represent more than 50% of the 200,000 unvaccinated, she estimated.
Among the possible reasons why they have not yet been inoculated, she said they may not have a family support system, lack of access to technology, including mobile phones to make appointments, and lack of transportation, since not all live in urban areas. She also mentioned that other factors may be that they do not believe in the vaccination, that they are influenced by relatives who do not believe in the vaccine, or because their relatives do not have the time to take them to get vaccinated because they get out of work after 5 p.m., when the vaccination centers have already closed.
“I add to that the indifference factor that has always existed,” she said about people who know that, for example, their neighbor lives alone and they do nothing to help.
Sánchez Salgado said it is “concerning” that these older adults have not received the vaccine yet, since this population is prone to infection, hospitalizations, and death, due to their compromised immune system and pre-existing conditions.
In fact, Dr. Vanessa Sepúlveda, an internist and geriatrician, told the CPI that, according to her experience in the Geriatrics Unit of the University of Puerto Rico Hospital, there were patients, older adults, who died of COVID because they were not vaccinated due to negligence of their relatives.
The Ombudswoman said, given this scenario and after the allocation of federal funds, they opened a call center in October [787-957-3000], hired companies to vaccinate in elderly homes and planned with the municipalities to provide transportation so that older adults can get to vaccination centers.
A CPI investigation revealed in July that the communities with the lowest vaccination rate in Puerto Rico during the first two and a half months of inoculation mostly had transportation problems that held them back from getting vaccinated.
Sánchez Salgado revealed that she approached the Puerto Rico State Elections Commission between May and June to get them to share the list of more than 100,000 bedridden people who they visited to collect their early vote in the electoral process in late 2020, but the government agency claimed that the information was confidential. So, she proposed preparing stamped cards which the SEC could send directly to the people, but this was also turned down. The effort “stayed in [the] coordination [stage],” even though the electoral commissioners had already approved it. The Ombudswoman also gave up on her proposal because, after analyzing it, she realized it was not economically viable for the agency that she directs.
The lower middle class affected the most by the pandemic
Pandemic-related deaths have affected the island’s lower middle class the most, according to an analysis by Dr. Julio César Hernández, associate professor of the Department of Agricultural Economics and Rural Sociology at the University of Puerto Rico in Mayagüez.
The deaths during the pandemic have affected the island’s lower middle class more, according to an analysis by Hernández.
The researcher explained that these deaths have occurred in communities with a working class population, with annual incomes of between $19,000 and $24,000. In fact, at the peak in December, the median income of the deceased, which includes the entire family nucleus, was $22,000, and $21,000 during the peak in August.
Stay-at-home spouses and manufacturing industry workers were hit the hardest in terms of COVID deaths, according to Hernández’s analysis. Both groups come from lower-middle-income communities.
He noted that the large number of deaths of stay-at-home spouses — as the Demographic Registry calls them — may be because they were contaminated by “blue collar workers” who are part of the household, such as husbands.
However, the Registry declined to explain exactly what this category means, or why there is no comparable one for men or people from the gender-diverse community. Deceased males appear under the category of stay-at-home wives, although the majority are women.
Regarding the deaths in the manufacturing industry, Hernández said due to the nature of the work, production lines call for “imposing a chain of indirect contact among people” and that the deaths in this industry suggest that no engineering controls and distancing measures were taken. Hernández specifically investigated the food industry and was able to determine that, even though it is a safe industry, distancing measures were not followed.
Excess deaths from all causes in Puerto Rico
Puerto Rico has seen excess deaths from all causes during most of the COVID-19 pandemic, according to a comparative analysis of the 2020 and 2021 Demographic Registry mortality data versus the average number of deaths in the previous five years. Excluding the atypical year of Hurricane María in 2017, when deaths soared in Puerto Rico due to the natural disaster, the excess mortality during the pandemic is even higher. This means it’s possible that there were COVID-19-related deaths that were attributed to other causes during the period. Despite this trend, the Government eased and eliminated protection measures to avoid infections and deaths.
The excess number of deaths began in March 2020 when the government announced the official onset of COVID-19 on the Island and continued until April 2021, except for a few months. The months that have followed in 2021 could also have excess deaths, but it is impossible to determine it yet because the Registry’s data is incomplete.
More-than-average deaths for this period are 3,222, while official deaths from COVID-19 during that same period totaled 2,462. In other words, there were 760 deaths above the usual attributed to other causes that could be linked to the virus, according to the data.
The analysis also showed an increase in deaths caused by diseases of the circulatory, endocrine, respiratory, nervous, and mental systems in 13 of the 17 months analyzed.
In the case of the circulatory system, there were increases in deaths from heart attacks and hypertension. In the endocrine system by metabolic and nutritional diseases; in respiratory diseases due to pneumonia; and in the nervous system, due to Alzheimer’s. Deaths from mental illness were from organic dementia, mental or behavioral disorders due to use of psychoactive substances, and schizophrenia.
Deaths from Alzheimer’s — a condition that is considered a neurological disease, not a mental one, but that affects the brain and memory — showed an excess during March, April, May, July, August, and November 2020. Also, from January to May of this year there was a spike in deaths of between 15% and 32.5% above the average of the previous five years.
Dr. Vanessa Sepúlveda, geriatrician and expert in Alzheimer’s, said there was a 16% increase in deaths in stateside patients with dementia or Alzheimer’s during the pandemic, and it was not necessarily because they were infected with the virus, but for secondary aspects, such as changes in their routines. She said this same situation must have been reflected on the island.
However, she said according to a study published in the Journal of Alzheimer’s Disease, patients with dementia — such as Alzheimer’s — also have more risk factors for getting and dying from COVID.
“It has been shown that one in four people with dementia who get COVID have a higher risk of mortality, almost four times the risk of death than someone without dementia. And this responds to the vulnerability of this population, not only age, but also comorbidities and diseases that can be associated with dementia. We know that there are risk factors for dementia like Alzheimer’s, which are vascular, diabetes, obesity. These are risk factors for COVID and become comorbidities and diseases that often come with dementia as well,” said Sepúlveda.
Dr. Sepúlveda added that, according to the experience of professionals during the pandemic, another factor that increases the mortality of these patients is being in long-term care homes.
“A patient with direct care, a caregiver at home, is not the same as a dementia patient who is in a long-term care home,” explained the founder of the organization “Un Café por el Alzheimer.”
She added that another factor that greatly affected and continues to affect patients with dementia is their atypical showing of COVID.
“Dementia patients aren’t necessarily going to have a cough and fever. No, patients with dementia many times won’t have a cough, nor will they have a fever because, due to their age, these responses to infections decrease, their thermostats [don’t work the same],” she said.
“This can delay diagnosis and treatment. And we know that this disease [COVID] must be treated within the first three days,” she said.
Older adults with Alzheimer’s may express delusions, acute confusion, mood swings, increased falls, and changes in behavior, she added.
Another important point she mentioned is that depression can increase in this population of older adults and patients with dementia. “All of this is an indirect consequence of the pandemic because these patients will not be able to access early treatment for this disease,” she said.
She cited another study done with 6,000 adults, which found that 73% of patients with depression had cognitive problems. “We’re talking about these patients having a deterioration in their memory and in their cognitive process; a deterioration in their functionality; that this patient spent more time sitting; that this patient’s day care services were suspended due to the pandemic, all of their routines, including going for a walk and being able to spend time with their family,” she said.
Deaths associated with mental conditions soar
Deaths from mental illnesses also reflected an excess during the months of May, June, and August 2020 and from February to June 2021. Within this cause of death, deaths from mental or behavioral disorders due to the use of psychoactive substances had a higher increase in 10 of the 17 months analyzed. Psychoactive substances are both illegal and legal drugs, including tobacco, alcohol, and opiates, as psychiatrist Arnaldo Cruz explained.
Given the spike in deaths from substance use and mental health conditions during the pandemic, psychiatrist Raúl López mentioned as a theory the possibility that this public health emergency, like Hurricane María, had a harmful effect on the emotional stability of certain groups and that this has affected the body systems, causing death.
He explained that, for example, no one dies from schizophrenia per se, but the schizophrenic, by the nature of their illness, may smoke excessively when their illness is exacerbated.
“Because obviously stress is not what kills directly. What indirectly kills is the impact stress has on the brain’s ability to regulate pre-existing conditions,” he said.
Meanwhile, regarding deaths from psychoactive substances, he said that at the end of 2020 the amount of alcohol sold was “unprecedented” and that, according to what was seen in his practice, patients were desperate because they could not leave their homes.
“All mental conditions, some more directly, some less, all have a systemic indication in the body. If you add a stressor that promotes risk factors, then you have the perfect storm. Perhaps it’s what you’ve been observing in all this data,” he said.
In addition to deaths under the current categories of mental health and substances of the International Classification of Diseases (ICD 11), which is the global system for categorizing physical and mental illnesses used to decide the cause of death, there are other deaths that are also related to the use of substances or drugs, which are classified as external deaths. These include drug overdoses, which according to preliminary data from the Puerto Rico Institute of Forensic Sciences, have not shown a spike.
However, IFC Director Dr. María Conte said they are seeing a dramatic increase in deaths caused by fentanyl, a synthetic opioid like morphine but 50 to 100 times more potent. This even though not all deaths in 2020 and the first six months of 2021 due to overdose are identified given the time it takes for toxicological test results. She said the IFC laboratory went through a period when tests were not being done due to the pandemic, so they are still closing cases from 2020.
Psychiatrist Karen Martínez, who was part of the defunct COVID-19 medical task force, said that countries like England are also seeing this increase in deaths from mental health causes. In addition, she said mental health professionals are not surprised, because literature before the pandemic had already described how having a severe mental health condition cuts back between 10 and 15 years of life.
Martínez explained that included in the reasons for this decrease in a patient’s life expectancy is the fact that they stopped seeking help for other medical conditions. Furthermore, these patients, who may have schizophrenia, severe bipolar disorder, among other disorders, may face cognitive changes that may not allow them to fully understand the recommendations given by their doctors and don’t follow instructions.
She also said severe mental health conditions can also affect physical health and cause, for example, metabolic conditions. She also noted that medications for severe mental health conditions also have side effects that worsen a patient’s metabolic profile.
The psychiatrist, who directs the Center for the Study of Fear and Anxiety of the University of Puerto Rico’s Medical Sciences Campus, said mental health professionals are also working with the distrust of patients in protection measures against COVID and vaccination.
Deaths by suicide, which are not classified in the mortality database under mental health but as deaths from external causes such as murders and accidents, have not registered an increase during the pandemic.
As for deaths from psychoactive substances, Martínez said she is not surprised that this has happened, since “we know that during the pandemic there was an increase in the use of both alcohol and psychoactive substances.”
“I believe that these data help us understand that, at the public health level, when we’re thinking about the populations that are most vulnerable to the negative effects of disasters, of unforeseen events such as a pandemic, we have to include the people who have a mental health condition,” she added.
While experts know about the increase in mortality in this population, these data validate that in times of emergency this is another of the populations that must be treated as a priority “because they could have negative consequences,” she said.
“We have to make sure that we have enough mental health professionals to provide services, because there’s going to be an increase in the need for service. And we’re seeing it, that right now people are having a very difficult time getting an appointment for mental health services,” she said.
Given this reality, it could be considered that primary physicians receive training to work jointly with mental health professionals to manage patients with mental conditions who visit physical health physicians to confirm that they are stable, she said.
Dr. Cruz María Nazario, epidemiologist and professor at the University of Puerto Rico’s Medical Sciences Campus, classified mental health deaths as “a multi-causal problem” that has different points of origin, which were not identified and intervened with in a timely manner.
“So, the long-term effect in terms of mental health is possibly going to last for many years. How many children are eventually going to have to depend on medications for the rest of their lives because [their mental health] wasn’t treated in a preventive way?" she said referring to the closure of public facilities for children’s mental health in Puerto Rico.
The harmful impact of telemedicine
Excess deaths related to the circulatory system occurred in March, April, June, July and August 2020, and in May 2021.
Cardiologist Luis Molinary said there is still a significant percentage of people who do not want to leave their home for fear of catching COVID, since there have been “peaks and valleys” during the pandemic, or times when infections decrease and periods in which they increase significantly.
“We’re all saying, all the time, that we’re doing better, but this isn’t over. For many of our elderly patients who want to take care of themselves, this means ‘don’t go out yet’,” he said.
Molinary said another reason for the spike in heart-related deaths, including hypertension, was because doctors began using telemedicine in 2020, which he says is not the appropriate way to care for patients with cardiovascular conditions.
“There is nothing to replace the in-person physical examination, touching the patient when examining them, taking their blood pressure, because when you’re on a phone doing telemedicine, you have to trust that the patient has a machine that is reliable to know if they have high blood pressure or not,” he said.
He added that, when resorting to telemedicine, doctors prescribe the same drug, which perhaps is not the most suitable for the patient because it must be adjusted. This can prompt the patient to go straight to the hospital when they don’t feel well.
Meanwhile, Dr. José García Mateo, president of the Puerto Rican Society of Endocrinology and Diabetology, also said telemedicine caused inadequate monitoring of endocrine conditions during the pandemic.
Deaths related to diseases of the endocrine system increased by as much as 23% compared to the average of the previous five years in the months of February, April, May, and August of 2020, and in April and May of this year.
He explained that for these patients it is necessary, for example, to measure their vitals, touch their neck to evaluate the thyroid nodules, evaluate pressure and pulse, and be able to look at their feet, if they are diabetic.
“Relying on an image from a camera to be able to make a clinical judgment, or a therapeutic decision, is very difficult. And I think that was what led to these patients having less follow-up, less treatment and many patients coming to my office who had gone without treatment for months,” he said.
This led to their conditions getting out of control, which in some cases ended in death.
In the case of patients who were infected with COVID and already had an uncontrolled metabolic condition, they were more at risk of complications and mortality from COVID, he said. But he said if patients had their metabolic or endocrine conditions under control, the chances of complications by having COVID were slim.
García Mateo said most of the patients who suffered complications because their conditions got out of control and even died, was because they followed the extreme protection measures, the confinement, and that they did not follow their treatments, sometimes because their doctors stopped offering services or offered them partially, only through telemedicine.
He said that the increase seen in deaths from nutritional causes, up to 89% compared to the average of the previous five years, could be due to a “poor diet,” high in calories and fat, since many people began to eat canned food and cold cuts to avoid trips to the grocery store.
Nutrition in Puerto Rico is not very good in general and that like the Hispanic countries, culturally, the food contains many calories, saturated fat, carbohydrates and a high glycemic index,” he said. “We have this problem in which people want to buy things that would last longer and are obviously high in preservatives and unhealthy food,” he added.
Diabetes-related deaths only showed an increase during the month of April 2020 and in May 2021. However, the endocrinologist said if people with this disease go for long with an uncontrolled condition, the jump in mortality could be seen further down the road.
“Patients are now coming to the hospital saying, ‘I’ve been vaccinated already, I’m going to seek medical help,’ and when they arrive, their condition is already complicated. They get here with general failure, with respiratory failure, with cardiovascular and stroke incidents, with amputations, because they arrive with a leg that wasn’t cared for and an ulcer that wasn’t treated, and it has already reached the bone and what’s left to be done is an amputation,” the endocrinologist said.
Pulmonologist Luis Echegaray said excess deaths related to respiratory system conditions recorded during the month of March and August 2020 could be due to a paperwork problem. He explained that many patients were not tested for COVID because at that time the tests were “not as available” and because post-mortem tests were not being done.
He added that paperwork was unclear.
“Like with any novel virus that happens in humanity, many people are going to die who didn’t even know they died from it,” he said.
He recalled the case of a patient under the care of Dr. Fernando Cabanillas, who was not tested, despite his symptoms. After he died, it was confirmed that he did have the virus.
Regarding excess deaths from pneumonia in the months of March and August 2020, and March 2021, he said “usually the number one cause of death in COVID patients is pneumonia,” so the increase could be linked to the virus, although it has not been identified as such.
On the pneumonia-related deaths registered in March this year, the pulmonologist said this increase was due to the Delta variant, since it left India in February and spread throughout the world. “Puerto Rico had the largest wave of Delta for March 2021. So, you have to place blame on two things: the end of government restrictions, because cases had dropped significantly, and that the Delta [variant] emerged at the time,” Echagaray said.
The pandemic’s greatest impact
Nazario insisted that the pandemic exposed all the problems of the island’s health system. The dismantling of the public health structure in the 1990s means that during this emergency there is no capacity to avoid preventable deaths, she explained.
In Nazario’s opinion, based on the premise that the health system is private, and whose mission is to make money, is when “health that isn’t visible, and the most important: mental health,” begins to deteriorate, and the real impact is just starting to be seen in mortality.
The greatest impact of the pandemic in Puerto Rico will be long-term in morbidity, or the aggravation of mental and physical conditions, she concluded.
Omaya Sosa Pascual contributed to this story.
The investigations were possible in part with the support of Para la Naturaleza, Open Societies Foundation and Fondation Connaissance et Liberté (FOKAL).