FORT LAUDERDALE, Fla. (Tribune News Service) — A heart attack after cleaning up debris. A missed dialysis appointment. An oxygen machine that blinked off when the power went out.

The death toll from Hurricane Ian is currently at 112 and still rising, making it the deadliest hurricane to hit Florida since 1935. Even as rescue teams pack up and return home, the number of those missing dwindling to single digits, the toll continues to climb.

The vast majority — more than 70 — of those deaths are still the drownings that occurred amid the storm surge and flooding Ian unleashed across the state. Many died in the water that filled their homes and cars. Some were carried away by the sea.

But the deaths that keep inching the toll upward are now the indirect ones: the heart attacks and suicides, the infections and injuries, and the inability to receive vital medical services.

While people tend to focus on the direct casualties after a major hurricane, it is the indirect deaths that often claim the most lives. Recent research on past hurricanes suggests that those deaths will keep climbing in the coming weeks and months, and ultimately could number in the thousands.

Professor Hugh Willoughby recalled a friend of his wife’s, who worked at an adult day care center during Hurricane Andrew. The building itself survived largely intact, he said, and yet there were several deaths among the clients.

“It’s stress and the whole disruption and interruption and all the things that people hate about hurricanes,” said Willoughby, who teaches earth and environment at Florida International University and researches hurricane mortality. “If you were in fragile health, it hastened moving on from this world.”

Direct deaths a result of two main factors

Hurricane Ian’s storm surge and flooding resulted in at least 62 confirmed drownings in Florida, according to the Florida Medical Examiners Commission. At least another 11 people died directly from vehicle accidents, wind, and damage during the storm.

By the direct death count alone, Ian already diverges from recent major hurricanes like Irma in 2017, Michael in 2018, and Andrew in 1992, some of the most destructive the state has ever faced.

Of the 92 people who died in the U.S. after Hurricane Irma, 10 died directly, while 82 died indirectly, according to the National Hurricane Center report, a number that could be much higher according to studies of nursing homes in the months after the storm. The same is true of Hurricane Michael: only seven of the 50 counted deaths in Florida were direct deaths, five of which were drownings.

Those don’t include hundreds of other victims who may have died later and weren’t part of official tallies.

The high number of direct fatalities due to Hurricane Ian compared with prior storms is likely due to two main factors: the deadliness of Ian’s storm surge and flooding, and the number of those remaining in the storm’s path when it hit, particularly older people with health conditions.

Many residents chose to stay put. Some didn’t expect the storm to be as bad as it was, or believed they were outside of its direct path, which shifted to the south as Ian neared landfall. Others couldn’t afford to evacuate, or felt they had no choice because their bosses told them they had to work. Evacuation orders gave some residents only a day to prepare their homes and leave.

“They don’t feel as threatened by hurricanes on the west coast,” Willoughby said. “It’s really unusual for a storm as intense as Ian was to strike the west coast of Florida.”

In fact, the west coast proved more vulnerable when the right factors came together, Willoughby said. The shallow warm waters offshore allowed greater storm surge to develop over a larger area, with none of the colder, deeper water that rises from below and tempers a storm’s intensity in the Atlantic.

And it’s the water, not the wind, which kills the most, Willoughby said, which also made Ian particularly deadly compared with other major hurricanes.

“Given the severity of the storm and the vulnerability of the communities — and even one death is too many — it could easily have been twice that or even more,” he said.

Indirect deaths linked to direct deaths

The circumstances that lead to higher numbers of direct deaths also contribute to indirect deaths.

The decision not to evacuate subjects a greater number of people not only to the initial wrath of the storm, but to all the ensuing consequences. Those include lingering loss of power and water at places like hospitals and nursing homes, flooded roadways, and backed-up emergency services.

“When storm winds die down, it still doesn’t mean 911 can get to you,” said Elizabeth Dunn, a visiting instructor at the University of South Florida’s college of public health who studies indirect deaths after disasters. “The call volume increases to a point where the fire service and police have to start triaging calls to find out who to go to first.”

Meanwhile, the greater severity of the storm creates more widespread, long-lasting damage that contributes to more indirect deaths.

Indirect deaths after a hurricane are typically thought to number approximately 10 times the number of direct deaths, said Willoughby.

The ratio holds up when applied to the official tallies of storms such as Irma and Michael. But researchers likely didn’t measure indirect deaths to their fullest extent in the past, Dunn said.

That changed after Hurricane Maria. A study from the Harvard Chan School of Public Health found that Maria had likely caused between 800 and 8,500 excess deaths in Puerto Rico.

“They really started putting a huge emphasis on indirect deaths after Maria,” Dunn said. “Some people were trying to diminish the number of deaths, saying ‘Oh, it’s only 64.’ Well, after people were dying because of not having electricity, dialysis, or clean drinking water, they started looking at deaths and causes.”

Heart problems drive indirect deaths after Ian

So what are those causes? The indirect deaths from Ian are beginning to appear in the Florida Medical Examiners’ Commission’s confirmed death report. Many haven’t happened yet.

Within that report, the leading major cause of death from Ian after drowning is not wind, structural damage, or vehicle accidents, but exacerbated health conditions.

Nearly two dozen people have died as a result of some kind of heart condition during or after the storm. In the report, medical examiners cited things like “physical exertion” and “stress from Hurricane Ian” as contributing factors.

“When you’re stressed out and your adrenaline’s running, there’s a level of uncertainty as you don’t know what’s going to happen,” Dunn said. “You have to understand that puts a lot of stress on you, your heart, and your physical health.”

After Hurricane Irma, a study of Florida nursing home residents attributed an additional 695 deaths to the storm. They compared the underreporting of nursing home deaths after Irma to the underreporting of COVID-19 deaths during the early days of the pandemic.

“The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters,” researchers concluded. “These risks may be underreported by state and federal agencies.”

Factors that contributed to those deaths included the “transfer trauma” of having to relocate due to evacuations and heat exposure due to power outages.

The same phenomenon is already playing out after Ian; hospitals in Southwest Florida had to evacuate patients while nursing homes in Central Florida coped with flooding and power outages.

A woman in Charlotte County was unable to get dialysis for more than a week, then died of medical complications. A woman in Orange County died after falling at her nursing home, fracturing her hip. Her surgery was delayed because the hospital had no running water.

Dunn is hopeful that, learning from past errors, researchers and medical examiners are trying to more accurately capture Ian’s toll this time around.

“The medical examiner is looking through each individual death,” Dunn said. “Asking, would this have happened if the storm never occurred? If that light at that intersection wasn’t out because the storm knocked out power? If that person wasn’t on that ladder trying to remove debris from their roof, would they have fallen and died?”

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