A long-awaited George Washington University study estimating the death toll in Puerto Rico as a result of Hurricane Maria has found that the number of excess deaths in the months that followed was many times that of the government’s official death toll, and was the most deadly natural disaster in the United States in more than a century.

In the new report, which was commissioned by Puerto Rican Governor Ricardo Roselló, GWU’s Milken Institute School of Public Health “estimated there were 2,975 excess deaths in Puerto Rico due to Hurricane Maria from September 2017 through the end of February 2018,” according to a press release. GWU carried out the study by analyzing death certificates “and other mortality data” over the six-month period and comparing the number of deaths to the expected total “based on historical patterns,” the release said.

The official government death toll was 64 as of this month, but the number found by the GWU study is even higher than expected; in June, the Puerto Rican government released findings that an estimated 1,427 people died between September and December 2017 relative to the average over the same time period over the last four years. The GWU report says that over that time period (without counting the first two months of 2018), an estimated 2,098 people died.

If the estimates are correct, Maria will have been the largest death toll from a natural disaster in the United States since the 1906 San Fransisco earthquake.

President Donald Trump told Rosselló during a visit to the U.S. territory after the hurricane, when the government’s official death count was 16, that “we’ve saved a lot of lives” in comparison to “a real catastrophe like Katrina.”(1,833 people died after Katrina.) The study had harsh words for both the government of Puerto Rico and the federal government:

Key leader interview participants perceived inadequate preparation by the Government of Puerto Rico and the federal government, evidenced by the unsuccessful communication between municipalities and the COE, a disabled hospital system, deficiencies in communication among first responders, handling of deceased and lack of coordination of health personnel for refuges. Furthermore, key leaders expressed that Hurricane María revealed Puerto Rico’s social and health inequities.

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GWU also found that Puerto Rico’s poorest were the hit hardest, finding that the “risk of dying over this period was the highest (60 percent higher than expected) for people living in the poorest municipalities—and that the elevated risk persisted beyond February 2018,” according to the release.

In addition, GWU said that Puerto Rico “should develop methods to rapidly assess total excess mortality after natural disasters and to provide that information to the public,” and encouraged the government to develop better procedures to more accurately calculate the number of deaths from natural disasters in order to “quickly identify populations at risk and develop interventions aimed at protecting the most vulnerable citizens.”

“The results of our epidemiological study suggest that, tragically, Hurricane Maria led to a large number of excess deaths throughout the island. Certain group—those in lower income areas and the elderly—faced the highest risk,” the project’s principal investigator, Dr. Carlos Santos-Burgoa, said in the release. “We hope this report and its recommendations will help build the island’s resilience and pave the way toward a plan that will protect all sectors of society in times of natural disasters.”

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You can read the George Washington University study below.

Update, 3:56 PM ET: The AP reports that Rosselló has raised his government’s official death toll from 64 to 2,975.

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