A Puerto Rican national flag is mounted on debris of a damaged home in the aftermath of Hurricane Maria in the seaside slum La Perla, San Juan, Puerto Rico, Oct. 5, 2017. An independent investigation ordered by Puerto Rico’s government estimates that nearly 3,000 people died as a result of Hurricane Maria. The findings issued on Aug. 28, 2018, by the Milken Institute School of Public Health at George Washington University contrast sharply with the official death toll of 64. Credit: Ramon Espinosa | AP

The latest attempt to get an accurate death toll in Puerto Rico following last year’s Hurricane Maria paints a grim picture: 2,975 “excess” deaths could be attributed to the storm, according to George Washington University researchers. That’s 46 times more than the 64 deaths first reported last fall.

But the counting is far from over, and nobody should be surprised if the death toll in Puerto Rico reaches or exceeds 4,000 by the end of the year.

Here’s why: Many of the conditions responsible for continued excess deaths remain and are unlikely to be appreciably ameliorated anytime soon.

The initial count focused only on first-phase storm-related deaths, such as from falling debris, electrocution from downed power lines, infections, drowning and so on. However, as is often the case in large-scale natural disasters affecting regions with fragile infrastructures and large numbers of economically disadvantaged, high-risk populations, later phases are often deadlier.

In the second phase, people die because electrical outages shut down home-based respirators and kidney dialysis centers. Access to vital prescription drugs may be severely limited as supply chains grind to a halt, putting people with conditions such as heart disease, diabetes and asthma at serious risk.

In phase three, profound population vulnerabilities become increasingly apparent and deadly. The ferocity of Hurricane Maria and the lack of resources to rapidly recover exacerbated long-standing physician shortages, poor transportation systems and long-standing inadequacies in the power grid.

Although electricity has been mostly restored in facilities that run dialysis machines for people with kidney failure, the entire electrical grid in Puerto Rico remains fragile. And although the supply chain for necessary medications needed by people with serious chronic medical conditions has been essentially restored, getting an appointment at or transportation to a medical facility remains highly problematic — especially for people living below or near poverty guidelines, a reality for nearly half of the island’s population.

Medical access has always been a challenge for low-income people in Puerto Rico, where serious physician shortages existed long before last September’s catastrophic storm. For decades, doctors have been leaving for the mainland United States, seeking higher pay and better lifestyle opportunities for their families. Between 2006 and 2016, the number of physicians in Puerto Rico dropped from 14,000 to 9,000. Hundreds more have left since Hurricane Maria, leading to severe staff shortages, the College of Physicians and Surgeons of Puerto Rico reported.

A month after the George Washington researchers completed their data collection, Wendy Matos, who runs the island’s largest network of medical specialists, noted that complications from chronic medical conditions had increased by at least 10 percent. “There is a serious problem with lack of access to health care in Puerto Rico,” Matos said. “Many residents need doctors but cannot travel [to the clinics] because they don’t have cars. Roads and transportation are ill-repaired and inaccessible.”

The island has also seen dramatic increases in calls to mental health and suicide hotlines — up from the typical 150 to 200 calls a day to about 500 following last year’s storms, said Puerto Rico’s health secretary, Rafael Rodríguez Mercado.

All of these factors contribute to an ongoing and lethal crisis in Puerto Rico. The faster that meaningful recovery can be implemented and underlying vulnerabilities addressed, the fewer storm-related deaths there will be.

Bear in mind, too, that there are important consequences from the long delay in acknowledging an accurate tally of Hurricane Maria’s deadly impact. The prolonged insistence on an absurdly low fatality rate allowed many to minimize the impact of the storm, failing to treat this extraordinary disaster with the urgency it warranted. Recall President Donald Trump’s repeated assertion that “we did a fantastic job” in responding to the disaster. If the president had deployed military assets sooner and more effectively, many lives may have been saved.

Even more problematic is that none of the budget proposals winding their way through the House and the Senate has any funding specifically set aside for hurricane recovery in Puerto Rico. Although nearly $14 billion has been appropriated for response efforts, it is dwarfed by the $139 billion needed for a full recovery that would make the island more resilient than it was a year ago.

Hurricane Maria has been one of the deadliest natural disasters in U.S. history, killing roughly the same number of people who perished on 9/11 and about 40 percent more than the number who died as a result of Hurricane Katrina in 2005. If Congress doesn’t help the more than 3 million American citizens who live in Puerto Rico recover from this catastrophic disaster, who will be held accountable?

Irwin Redlener directs Columbia University’s National Center for Disaster Preparedness and is a professor at the Columbia University Mailman School of Public Health. He is author of “Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do Now” and chairs the advisory panel for Somos Una Voz.

Follow the Bangor Daily News on Facebook for the latest Maine news.