After months insisting that the official death toll in Puerto Rico as a result of Hurricane Maria was accurate, the governor of the island has ordered a review of every death there.

The decision to take a fresh look at the death toll comes in response to mounting evidence that the official tally — 64 deaths — is greatly undercounted. Officials will now take a look at all deaths attributed to natural causes following the Sept 20 landfall of the hurricane, which knocked out power to 3.4 million Puerto Ricans, some of whom are still without power months later.

That prolonged power outage is critical to the argument that the official death tally is low. The blackout made the regular operation of critical medical treatment for some of the most vulnerable patients on the island incredibly difficult. As a result, some bedridden patients or patients dependent on dialysis or respirators may have died as a result of the storm — albeit not from direct impacts like flood drownings.

“This is about more than numbers, theses are lives: real people, leaving behind loved ones and families,” Governor Ricardo A Russelló said in a statement.

Outside estimates by news organisations have shown that as many as 1,065 people died as a result of conditions created by the storm. That estimate was compiled by Puerto Rico’s Centre of Investigative Journalism. Others, by the New York Times, indicate that 1,052 people died. A CNN estimate found that there were at least 499 more deaths than reflected in the official tally.

The 64-person-count is likely a reflection of varying methods for counting deaths following a hurricane disaster like Maria. State and local governments keep tabs in different ways. Some, for example, only count direct deaths, like those who die in flood waters. Still, the count in Puerto Rico isn’t restrictive, and the medical examiner has included deaths indirectly caused by the storm as well including suicides.

Bringing aid to Puerto Rico Show all 20 1 /20 Bringing aid to Puerto Rico Bringing aid to Puerto Rico Crew chief Kenney shelters under the blade of an HH-60 Blackhawk helicopter from 101st Airborne Division's "Dustoff" unit preparing to take off during recovery efforts following Hurricane Maria, in Isla Grande, Puerto Rico, October 6, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico An HH-60 Blackhawk helicopter from 101st Airborne Division's "Dustoff" unit takes off behind Crew Chief Alexander Blake and his fellow soldiers during recovery efforts following Hurricane Maria, in Morovis, October 5, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Crew member Bynum stands in tropical rain as a HH-60 Blackhawk helicopter from 101st Airborne Division's "Dustoff" unit prepares to take off during recovery efforts following Hurricane Maria, in Isla Grande, October 6, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico UH-60 Blackhawk helicopter pilot Chris Greenway receives a hug from a woman thanking him for water as he works with the First Armored Division's Combat Aviation Brigade during recovery efforts following Hurricane Maria, in Verde de Comerio, October 7, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico A man carries a case of water away from an HH-60 Blackhawk helicopter after soldiers working with 101st Airborne Division's "Dustoff" unit dropped off relief supplies during recovery efforts following Hurricane Maria, in Jayuya, October 5, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Crew chief Alexander Blake from 101st Airborne Division's "Dustoff" unit loads water into a helicopter during recovery efforts following Hurricane Maria, in Isla Grande, October 5, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Residents wait for soldiers in UH-60 Blackhawk helicopters from the First Armored Division's Combat Aviation Brigade to deliver food and water during recovery efforts following Hurricane Maria, in San Lorenzo Reuters Bringing aid to Puerto Rico An HH-60 Blackhawk helicopter from 101st Airborne Division's "Dustoff" unit lands in a field to avoid lightning during recovery efforts following Hurricane Maria, in Manati, October 5, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Residents hold their hands aloft to signal that they need water as UH-60 Blackhawk helicopters from the First Armored Division's Combat Aviation Brigade fly past during recovery efforts following Hurricane Maria, near Ciales, October 7, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Tropical rain splashes on a runway as HH-60 Blackhawk helicopters from 101st Airborne Division's "Dustoff" unit wait for weather to clear during recovery efforts following Hurricane Maria, in Isla Grande, October 6, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Pilot Eldwin Bocanegra Torres speaks with residents isolated by landslides in the mountains after unloading water and food from a helicopter during recovery efforts following Hurricane Maria, near Utuado, October 10, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Residents stand in front of wind-damaged trees as they wait for soldiers in UH-60 Blackhawk helicopters from the First Armored Division's Combat Aviation Brigade to deliver food and water during recovery efforts following Hurricane Maria, in San Lorenzo, October 7, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico The contents of a home are seen from the air during recovery efforts following Hurricane Maria near Utuado, October 10, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Thomas looks out of the window of an HH-60 Blackhawk helicopter from 101st Airborne Division's "Dustoff" unit, loaded with relief supplies, during recovery efforts following Hurricane Maria in Isla Grande, October 6, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico A message written on the rooftop is seen from the air during recovery efforts following Hurricane Maria near Humacao, October 10, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico A HH-60 Blackhawk helicopter from 101st Airborne Division's "Dustoff" unit lands in a field during recovery efforts following Hurricane Maria in San Sebastian, October 6, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Sergeant First Class Eladio Tirado, who is from Puerto Rico, looks for a landing spot for a UH-60 Blackhawk helicopter from the First Armored Division's Combat Aviation Brigade, during recovery efforts following Hurricane Maria near Ciales, October 7, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Boys carry water away from an HH-60 Blackhawk helicopter after soldiers working with the U.S. Army's 101st Airborne Division's "Dustoff" unit dropped off relief supplies during recovery efforts following Hurricane Maria, in Jayuya, October 5, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Sergeant First Class Eladio Tirado from the First Armored Division's Combat Aviation Brigade, who is from Puerto Rico, speaks with residents as he helps during recovery efforts following Hurricane Maria, in San Lorenzo, October 7, 2017 Reuters/Lucas Jackson Bringing aid to Puerto Rico Residents peek through a fence at helicopters from 101st Airborne Division's "Dustoff" unit that had parked in a locked field during recovery efforts following Hurricane Maria, in Lares, October 6, 2017 Reuters/Lucas Jackson

While the leading cause of death on the island in September were diseases like diabetes and Alzheimer’s disease, the island did see a surge in deaths from sepsis this year, a complication of infection that can be connected to slow medical treatment or unsanitary living conditions.