SAN JUAN, Puerto Rico (AP) — 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.
"Nobody rebuilding his or her life after a natural disaster should suffer the negligence we've seen in Puerto Rico," Rep. Raul Grijalva of Arizona said. "Too many Puerto Rican families are suffering additional burdens today because officials won't acknowledge their loved ones' deaths.
Like Perez, thousands of sick Puerto Ricans were unable to receive medical care in the months after the storm caused the worst blackout in U.S. history, which continues to this day, with 6,983 home and businesses still without power.
The data released Tuesday showed increases in several illnesses in 2017 that could have been linked to the storm: Cases of sepsis, a serious bloodstream infection usually caused by bacteria, rose from 708 in 2016 to 835 last year. Deaths from diabetes went from 3,151 to 3,250 and deaths from heart illnesses increased from 5,417 to 5,586.
The data was not broken down by month, preventing an analysis of whether the illnesses rose after Hurricane Maria.
CNN and the Puerto Rico Center for Investigative Journalism sued the Puerto Rican government after it refused to release a detailed accounting of deaths in the wake of the storm. On June 5, a judge gave the government until Tuesday to release a database listing the causes of death of all those who died from two days before the storm until today, along with all the death certificates and burial and cremation certificates for the same period.
"People still don't have a clear picture as to how many lives were lost due to a lack of food, medicine, health services or simply because of an ineffective response to an emergency. That's why it's urgent to shed light on all components of government preparedness and response," Judge Lauracelis Roques wrote in her ruling.
The government on Tuesday requested more time to release all the death certificates, saying Social Security data had to be redacted from 48,000 individual documents. The judge rejected the request and the government planned to announce its next steps later in the day.
Meanwhile, thousands of Puerto Ricans were hoping the release of the information will lead to their loved ones being included in the storm's toll, something they say will provide a sense of closure and show the American public the true cost of the hurricane.
Until now, Perez has been "one of those who do not count," his daughter told The Associated Press. "That's a lie."
Lucila Pardo, 96, spent nearly four months in a sweltering nursing home that did not have power and developed bed sores by the time she was moved in early January to another home where electricity had been restored. By then, the sores had become infected and she was taken to a hospital where she spent two weeks before dying of septicemia.
"That figure of 64 is a lack of respect for those who died from other consequences," said Pardo's granddaughter Analid Nazario.
"The hospital wrote a letter apologizing," Nazario told the AP, adding that they were understaffed.
A Harvard study published last month estimates there were as many as 4,600 more deaths than usual in the three months after Maria, although some independent experts questioned the methodology and the numbers in that study. Still, previous studies have found the number of direct and indirect hurricane-related deaths is higher than the official toll, including a 2017 report that said there were nearly 500 more deaths than usual on the island in September.
Days before the government was ordered to release the new data, Puerto Rico's Institute of Statistics sued the demographic registrar for the information. On June 1, the agency released information showing there were an additional 1,397 deaths from September to December 2017 compared with the same period the previous year.
Among those who died the first week of October was Raul Antonio Morales, a 95-year-old diabetic who didn't have the insulin he needed because the nursing home where he lived didn't have power or a generator, according to his granddaughter, Maytee Sanz. She said relatives tried to obtain a generator, but there was none available. A doctor at the nursing home certified that Morales died of natural causes, and he is not included in the official death toll.
"I think the government has been extremely inept and inefficient regarding the statistics," Sanz said. "There were a lot of deaths certified as natural simply because they ... were not electrocuted or did not drown, but they were a result of the hurricane. When you don't have access to insulin or a respiratory machine, you have no way of surviving."
Associated Press writer Larry Fenn in New York contributed to this report.