How a death is determined to be disaster-related

After María a wound was left that was not only the count: families with a death certificate saying “natural causes” over a death everyone in the house knew happened because there was no power, no oxygen, no road to the hospital. This 2023 Act is the answer to that. It creates a protocol that switches on by itself when an emergency is declared, requires the certifying doctor to explain the circumstances and not merely enter a diagnosis, and opens a centre at Forensic Sciences where the family can go, sit for an interview and contribute what they know. It also creates the committee that publishes the official figures and puts dates on it.

There is nothing to qualify for and no application to file: the protocol activates by itself. Article 6 says so without conditions: the protocol and the committee “shall activate immediately upon an emergency or disaster declaration in Puerto Rico, declared by the Commonwealth of Puerto Rico or by the Federal Government.” Either declaration suffices. What the family can do, and it is the part that falls directly to them, is go to the family attention centre at the Institute of Forensic Sciences for an interview and contribute information to the determination of the manner of death. The Act sets that step no kinship requirement, deadline or form, and we do not add them.

Information pending verification.

Information pending verification.

1. 1

   Step 1: The protocol switches on by itself, with the declaration

   It need not be requested or activated. Article 6: “The Protocol established in Article 4 of this Act and the Committee established in Article 5 of this Act shall activate immediately upon an emergency or disaster declaration in Puerto Rico, declared by the Commonwealth of Puerto Rico or by the Federal Government.” Either declaration suffices. Deactivation is not set by the Act: it leaves it to the Article 9 regulation, and provides it happen after the final report is rendered.

2. 2

   Step 2: What the family can do: the family attention centre

   It is the only door the Act opens directly to a relative, which is why it sits here and not at the end. Article 4(b) orders the “inclusion of cases at the family attention centre for deaths related to factors of catastrophic events or natural disasters at the Institute of Forensic Sciences, where the deceased person’s relatives may come for an interview and contribute information to the determination of the manner of death.” What you say there is not a courtesy step: it enters the determination. If in your home there were days without power, without water, without oxygen or without a way to reach the hospital, that is the fact the protocol needs and that nobody else has.

3. 3

   Step 3: The interview with the family nucleus is a duty of the doctor

   It does not depend only on the family coming forward. Article 4(d): “Forensic pathologists attached to the Institute and doctors working in hospitals, clinics and elsewhere shall conduct an interview with members of the deceased’s family nucleus to obtain information and determine the circumstances of the death and determine whether it is natural or accidental.” It is drafted as an obligation, not an option, and it reaches hospital and clinic doctors, not only forensic ones. If nobody in your family was interviewed, that is a departure from the protocol worth pointing out.

4. 4

   Step 4: The certificate must be filled in full, and someone can sanction

   Here is the Act’s tooth, and it is the paragraph most worth having to hand. Article 4(e): “It shall be the non-delegable responsibility of the doctor certifying the death to complete in its entirety the document provided by the Government to certify the death. In that document, the doctor must certify the cause of death and explain the circumstances that contributed to the passing, such that the Institute of Forensic Sciences has all the necessary information.” And it continues: “The Medical Licensing and Discipline Board is empowered to impose sanctions on any doctor who fails to comply with the provisions of this subsection,” under Act 139-2008. Two words do the work: “non-delegable” and “explain the circumstances.” A diagnosis alone is not enough.

5. 5

   Step 5: Where the record goes, and why the municipality is consulted

   Article 4(c) traces the paper trail. The certifying doctor “shall send the medical summary or a certified copy of the patient’s record to the Institute of Forensic Sciences for the corresponding analysis by the Forensic Pathologist and to the Registro Demográfico established by the Department of Health where such analysis need not be performed.” And it adds a surprising source: should there be doubt about the form or the death record, “the Municipal Offices for Emergency Management and Disaster Training of the 78 municipalities may also be consulted,” because they run the post-emergency censuses and “have direct information on each death in real time.” The subsection limits itself: “This provision shall apply exclusively during the period of the state of emergency or disaster.”

6. 6

   Step 6: The form, and what it must say

   Article 4(a) sets the minimum content. The Registro Demográfico and the Institute of Forensic Sciences “shall use a particular form which must contain the specific cause of death, demographic information on the decedent, specify whether it was from natural or external causes, in addition to the date and hour of death for the evaluation and classification of cases of deaths from factors related to catastrophic events or natural disasters.” Four items: specific cause, demographics, natural or external, and date and hour. The Act publishes neither the number nor the name of the form, and we do not invent it.

7. 7

   Step 7: Who publishes the figures and when

   Article 5 creates the Interagency Committee for the Official Release of Information on Statistical Data of Deaths Related to Natural Disasters or Catastrophic Events, with three members: the Director of the Institute of Forensic Sciences, the Director of the Registro Demográfico and the Executive Director of the Institute of Statistics, who may designate a representative. The Committee is responsible for releasing the Government’s official information, and it has a clock: first partial report within forty-five (45) days of activation, second partial report within one hundred twenty (120) days, final report within one hundred eighty (180) days, all conditioned on “the conditions of the natural disaster or catastrophic event so permitting.” The Governor may extend the final one at the Committee’s request, at thirty (30) days per extension. The reports are filed with the Secretariats of the Legislative Bodies and with the Governor.

8. 8

   Step 8: Indirect deaths are inside the count by statute

   It is the point most argued after María and the Act closes it in one line of Article 5: “the methodology developed by the Center for Disease Control and Prevention and the National Center for Health Statistics shall be required as to the methodological standards for facilitating the consistent identification of deaths related, both directly and indirectly, to a disaster.” “Both directly and indirectly” is not our reading: it is in the text. A death that happens because the disaster left someone without treatment, without electricity for their medical equipment or without access to hospital falls inside the method the Act orders used.

9. 9

   Step 9: The rest the Act orders, and why the figures should arrive sooner

   Three pieces that do not touch the family directly but explain the design. Article 4(f): in an epidemic, pandemic or any state of emergency declared by Executive Order, the Department of Health must send the Institute of Statistics its vital-statistics, morbidity and medical-service-use data “within not less than forty-eight (48) hours of its being generated or updated,” in machine-readable digital format and protecting personal data. Article 7 authorises the Institute of Forensic Sciences and the Registro Demográfico to sign agreements with United States jurisdictions accredited by the National Association of Medical Examiners if they lack sufficient staff when the protocol activates. And Article 8 orders that every doctor pass a training course on documenting causes of death on the death certificate.

The family attention centre is at the Institute of Forensic Sciences, which is where the Act locates the family interview. The certificate and the death record are processed through the Registro Demográfico, attached to the Department of Health. If the complaint is against a doctor who did not complete the document in full nor explain the circumstances, the forum the Act names is the Medical Licensing and Discipline Board. The Act publishes no address, telephone, hours or form for any of the three, and we do not invent them.

• Believing the protocol must be requested: Article 6 activates it on its own with the emergency or disaster declaration.
• Thinking only direct deaths count: Article 5 requires the CDC and NCHS methodology to identify those related “both directly and indirectly.”
• Accepting a certificate with a diagnosis and nothing more: Article 4(e) requires the doctor to explain the circumstances that contributed to the death.
• Not going to the family attention centre: what the family contributes there enters the determination of the manner of death.
• Assuming only forensic staff conduct the interview: Article 4(d) also obliges hospital and clinic doctors.
• Looking in this Act for a fine against the Government: the only sanction it creates is against the non-complying doctor, imposed by the Medical Licensing and Discipline Board.
• Counting on the consultation with the municipal emergency management office outside the emergency: Article 4(c) limits it to the period of the state of emergency or disaster.

These are the government pages this guide is based on.

• Departamento de Salud de Puerto Rico

  Salud

  bvirtualogp.pr.gov