SAN JUAN, Puerto Rico — Eight days after Hurricane Maria devastated Puerto Rico, Efrain Perez felt a pain in his chest.
Doctors near his small town sent him to Puerto Rico's main hospital for emergency surgery for an aortic aneurysm. But when the ambulance pulled into the parking lot in the capital, San Juan, after a more than two-hour drive, a doctor ran out to stop it.
"He said, 'Don't bring him in here, I can't care for him. I don't have power. I don't have water. I don't have an anesthesiologist,'" Perez's daughter, Nerybelle, recalled.
The 95-year-old Perez died as the ambulance drove him back to southwestern Puerto Rico but he is not included in the island's official hurricane death toll of 64 people, a figure at the center of a growing legal and political fight over the response to the Category 4 storm that hit Puerto Rico on Sept. 20, 2017.
Facing at least three lawsuits demanding more data on the death toll, Puerto Rico's government released new information on Tuesday that added detail to the growing consensus that hundreds or even thousands of people died as an indirect result of the storm.
According to the new data, there were 1,427 more deaths from September to December 2017 than the average for the same time period over the previous four years. Additionally, September and October had the highest number of deaths of any months since at least 2013. But the statistics don't indicate whether the storm and its aftermath contributed to the additional deaths.
The Puerto Rican government says it believes more than 64 people died as a result of the storm but it will not raise its official toll until George Washington University completes a study of the data being carried out on behalf of the U.S. territory.
The issue is clouded by the fact that the federal government and U.S. states and territories have no uniform definition of what constitutes a storm-related death. The National Hurricane Center counts only deaths directly caused by a storm, like a person killed by a falling tree. It does not count indirect deaths, like someone whose medical equipment fails in a blackout.
Puerto Rico began by counting mostly direct deaths, with some indirect ones. Then it stopped updating its toll entirely while it waits for the George Washington University study, due later this summer.
The death count has had political implications. Visiting Puerto Rico on Oct. 3, two weeks after the storm hit, President Donald Trump asked Gov. Ricardo Rossello what the death toll was.
"Sixteen," Rossello answered.
"Sixteen people certified," Trump said. "Sixteen people versus in the thousands. You can be very proud of all of your people and all of our people working together. Sixteen versus literally thousands of people. You can be very proud. Everybody watching can really be very proud of what's taken place in Puerto Rico."
On Monday, two Democrats introduced a bill to the Republican-controlled Congress that would establish federal procedures for counting deaths after a natural disaster, saying that will help improve the federal response and be key to allocating federal funds. The $2 million proposed project would allow the U.S. Federal Emergency Management Agency to hire the National Academy of Medicine to do a study on how best to assess fatalities during and after a disaster, given that the process is currently left up to U.S. states and territories.