Say you are found on your bathroom floor, on the grassy knoll of someone else’s front yard, in the berth of your tractor-trailer, in your own bed, at the foot of a bridge, under a car wheel, in the car, caught in the bend of a river, collapsed in the bar, alone in the remains of a scorched kitchen. Your death is sudden and unexpected, a death that no one plans for but that approximately half a million of us will experience this year in America. No death is special, but this kind of death requires special care, procedurally, from a number of people you will never meet. The procedural aspects of your death, which you will never see, begin with a phone call.
One afternoon in the summer of 2018 in Cleveland, a man returned home to find his wife slumped over her computer keyboard. She was in her 50s and had been in poor health, but nothing seemed urgent or life-threatening. It looked as if she died while shopping online. Her husband called 911.
When police officers arrived at the house, they weren’t entirely sure what had happened. It looked maybe like a cardiac episode, or a seizure, or an overdose. The woman had been taking a long list of prescription medications, and in Ohio, amid the ongoing opioid crisis, most untimely deaths with no obvious foul play are marked for further investigation. The officers called the medical examiner’s office, and Erin Worrell picked up.
As a medicolegal death investigator, Worrell serves as “the eyes, ears, and nose,” as she puts it, of the team that determines cause and manner of death for the official record. It’s often said that death investigators are “the last of the first responders,” in that they are called only after a life-or-death situation has reached its definitive conclusion.
Roughly 30 minutes after the officers called, Worrell arrived and began the standard investigation for a scene of this sort. She asked the husband when he last talked to his wife, when he came home, what her medical history was, whether he had any concerns or suspicions about her cause of death. She inspected the woman’s body to see whether her lividity patterns, which indicate the position of the body at the time of death, matched the husband’s story. She talked to the police officer to check her information against his, and she inspected the house for anything telling, like drug paraphernalia, weapons or an open gas valve on the stove. She took photographs all the while and made copious notes for the case file. Worrell confirmed what the detective suspected: Because there was no clear natural cause of death, the woman would need further evaluation and possibly an autopsy.
Generally, if a death is suspected to be unnatural (accident, homicide, suicide) or of special interest to the state (natural disaster, mass fatality or death in custody), the body belongs, temporarily, to the local coroner or medical examiner. Those officials evaluate and report the cause and manner of death, notify law enforcement and any federal agencies that may be involved in an investigation, like the D.E.A. or the Postal Service, and sign the death certificate (which is what declares a person finally, legally dead) before returning the body to the next of kin.
While they perform similar official tasks, medical examiners and coroners don’t have identical job requirements. Medical examiners must be forensic pathologists — doctors with medical-school training, plus a pathology residency and then further training in forensics. Sometimes coroners are forensic pathologists, but more often they are general physicians, or nonphysicians who work in other professions; typically, the requirements are significantly more lax.
No matter whether a state or a county runs on the medical-examiner system or the coroner system, in a vast majority of cases only a forensic pathologist can perform an autopsy of a body that appears to have died of unnatural causes; coroners who aren’t forensic pathologists outsource that labor. Eleven years ago, the National Research Council issued a warning that there were fewer than 500 forensic pathologists in the United States, a number that couldn’t cover even half the annual deaths that require autopsy. (For scale, there are more than 12,000 dermatologists.) In the years since, the opioid epidemic has increased their caseload so drastically that the system is threatening to collapse. In the last 10 years, medical examiner’s offices with a glut of cases have lost accreditation with the national supervising association. The bodies in their districts are often shipped to other offices — which then become overloaded and risk losing accreditation in turn.
There are coverage deserts, huge (mostly rural) parts of America that lack ready access to autopsies or trained death investigators. For a month in 2015, anyone who died in Montana had to be transported to South Dakota or Washington if an autopsy was needed; in Wyoming, bodies often have to cross state lines because there are no forensic pathologists nearby. For several years, Oklahoma’s overloaded medical examiner declined to perform autopsies on people over 40 who died of unexplained causes; the office still does not perform them on anyone who seems to have died by suicide. Chief medical examiners of New Jersey, Los Angeles County and Cook County, Ill., (all offices serving millions of people) have resigned in protest over intolerable case loads and insufficient funding and resources.
But the problem in Ohio is especially dire. Over the past few years, news outlets reported that bodies there were being stacked two to a gurney and piled in refrigerator trailers to catch the morgue overflow. Worrell’s boss, the Cuyahoga County medical examiner, Thomas Gilson, compared it to a flood in an interview with The Wall Street Journal. “We’re just really awash in drug deaths,” he told the reporter. Cleveland has one of the largest and best-equipped facilities in the county, but it had a refrigerator trailer parked out back too, just in case. It was a rare public-facing cry for help from a community of professionals who, despite being crucial agents of public health and safety and stewards of our final days on earth, remain largely out of sight. Prominent members of the field, like Gilson, have been striving to demystify their work and its stakes: When death investigators and forensic pathologists don’t have the time and resources to do their jobs thoroughly, avoidable deaths follow.
Autopsy results would show that the woman who died at her computer was another opioid death, part of the epidemic that was crushing the system. When the time came to remove the woman, Worrell took the husband aside and suggested that he step out; they had to put his wife in a body bag, which he didn’t need to see. He looked startled. “Can we pray?” he asked finally.
“Sure,” Worrell said immediately. “We can pray. I’ll get anyone you want to come and pray.” She called in the detectives, as well as the contractors who were there to pick up the body and transport it to the medical examiner’s facility, and asked them to stop what they were doing. She set down her notepad. Some neighbors and friends had come to the house after hearing the news, and together they all stood and held hands. They recited the Lord’s Prayer.
Afterward, Worrell and the contractors resumed the routine. They lifted the woman into a body bag, zipped it shut and loaded her into the van, which made its way to an office park in University Circle where Gilson and his team work. The van went around back, to the wide bay door that serves as the entrance for what I once heard a medical examiner call his “silent clients.” Through that door is the morgue.
At the Cleveland office, every morning begins with a staff meeting. Around the table are all the forensic pathologists, along with at least one representative from every team that touches a body during its journey through the system: death investigators, morgue technicians, trace-evidence technicians, fingerprint specialists, toxicologists, drug chemists. At 8:30 a.m., Gilson sweeps through the door to the conference room and shuts off the lights.
One by one, the cases that have come in since the meeting the day before appear on a projector screen. Death-scene photos flash past in a slide show while a deputy medical examiner, a thin, studious man named David Dolinak, reads aloud each case report. At this point, the coordination begins: If the deceased is a John or Jane Doe, the death investigators will work with a series of specialists to try to confirm an identity and next of kin. The pathologist doing the autopsy may request to inspect some items in the trace department, like a vial or bullets recovered from the scene. Before the team moves on to another case, the initial determination is made: “We’ll do an external examination” or “She is for autopsy.”
Gilson invited me to chat after the meeting, and I followed him to his office, a windowed executive suite furnished with a giant wooden desk, a microscope, a tidy blue sofa and mountains of folders and papers. Gilson’s manner is sober yet affable; he is the only pathologist in the office who prefers silence to music while performing an autopsy, but he ends staff meetings each evening with his personal maxim, “Celebrate the day.” He has a record of taking poorly functioning offices and restoring their accreditations and standard of care. He came to Cleveland in 2011 after a series of scandals led to a staff overhaul.
“I really feel like forensic medicine is kind of this undiscovered continent in public health,” he explained. “It has so many implications: gun violence, the drug crisis, natural diseases like the flu.” Gilson often points out that the C.D.C. statistics on injury and mortality are compiled from information that originates in offices like his, and that the level of investigation they do on each case means they have a much richer, more granular compendium of information and data than can be communicated in C.D.C. reports. “This is actually where all of that information is stored,” he said. “And how do you use that fact to start to develop prevention strategies?”
In 2012, Gilson’s office was among the first to put out the first public-health warning about a rapid rise in unexpected heroin overdoses. A young toxicologist had noticed that heroin was quickly spreading throughout the county, to neighborhoods and populations that had never struggled with it before. With other municipalities, the office formed a task force to study the epidemic as it evolved in Cleveland and the surrounding areas and began sounding the alarm. It found that a high percentage of overdoses happened in the presence of someone who could have intervened before paramedics arrived, so it worked with the cities to start trainings and better distribution for naloxone, a drug that can reverse a narcotic overdose. It also found that many people were overdosing shortly after being released from prison — prompting law enforcement and local prisons to educate inmates about the risks before their release.
Nationwide, the medicolegal death investigation system, as it’s called, is the primary source of data that drives our understanding of what’s killing us that shouldn’t be. Gilson regularly appears on local news programs to warn about timely risks, like drownings in the summer, and the death investigators alert city planners when they spot an intersection where car accidents are common. It was a medical examiner who, in 2015, confirmed the first measles fatality in more than a decade — a diagnosis that turned up only through an autopsy, because the victim had no typical measles symptoms — prefiguring the measles epidemic that has plagued the U.S. in the past year. Coroner reports helped the C.D.C. link more than 50 unexplained deaths to methylene chloride, a chemical common in paint strippers, which led to an E.P.A. ban on consumer sales of the chemical.
After mass shootings, acts of terrorism or natural disasters, medical examiners or coroners are put in charge of the bodies at the death scene, working to identify them, matching bones to their mates, gathering medical information that might indicate what weapons were used and how and compiling the investigative data they draw on as expert witnesses in criminal trials. (Many offices have complex mass-fatality preparedness plans, developed in tandem with local government, and run regular drills.) They are also seen as key players in bioterrorism-response plans by state and federal governments, because they, along with hospitals, are the fastest reliable identifiers of a new toxin or disease that has entered the population.
The rate of autopsy in hospitals is now under 5 percent, so a majority of public-health information drawn from autopsies is coming from the medical examiner-coroner system. The information the system gathers provides the raw data that epidemiologists use to study everything from food-safety policy to patterns of domestic violence — like the 2008 study published in The Journal of Emergency Medicine showing that nonfatal strangulation by an intimate partner was a major indicator of future homicide.
The trouble, Gilson explained, is that most coroner and medical-examiner offices are so overloaded that forensic pathologists are struggling simply to finish their cases within the time frame mandated by the National Association of Medical Examiners (NAME). Even if an office can come up with the money to furnish an attractive salary for a forensic pathologist, there is often no one to hire. Stressed and disheartened by the workload, forensic pathologists change careers or retire early. Gilson pointed to David Fowler, the former medical examiner of Maryland, who retired early at the end of 2019, citing insufficient staffing and funding.
In 2013, NAME published the results of a survey of 68 offices in the U.S. that serve populations greater than 300,000; while 97 percent of the offices expressed interest in a medical-examiner-based surveillance system for infectious diseases, only 13 percent were identifying and reporting infectious-disease cases through the existing reporting methods, because of lack of money, lab-testing capability and staffing concerns. In 2017, testifying before a Senate subcommittee, Gilson called the shortage a “national crisis in death investigation,” reporting that his profession was in “dire need.” When I spoke to him in February, he said it’s only getting worse.
After we spoke in his office, I followed Gilson up to the trace-evidence department. He was about to demonstrate an autopsy for a group of visiting prosecutors. The deceased was an elderly man who hanged himself, and Gilson wanted to inspect the rope.
The man was laid out, naked and mottled, with the rope still attached to his neck and coiled neatly by his head. As Gilson greeted Daniel Mabel, the forensic scientist staffing the trace-evidence department that day, he asked, “Do you have the gun for the other guy?”
Mabel shook his head, then explained to me that he was working on the case of a black teenager found with a gun in his hand and a gunshot wound to the head. Detectives thought it was a homicide, but Gilson and his team thought it was more likely a suicide.
“You know,” Gilson said, “that’s a rising trend, suicide among young African-American males, that I haven’t heard a lot about.” He lifted the rope from the man’s neck and turned it over in his hand, inspecting its weave and weight. “We tend to think about suicide as older white guys or middle-aged white guys, which is still true. But if nobody’s following trends. … ” He waved his hand toward the morgue, where we had just seen a black teenager who had arrived the day before with a self-inflicted gunshot to the head. When his age was read aloud in the morning meeting, there was a collective intake of breath.
“Thirteen?” someone asked, as if hoping the number were wrong.
“I don’t want to harp on this,” Gilson said, setting the rope back on the table, “but if you overburden the system with casework, the surveillance function is lost.”
One April Saturday in Cleveland, the weekend staff — two investigators and one pathologist — were going quietly through the afternoon’s work when someone called to tell them that the coroner of a nearby county had died. This news was met with surprise and apprehension. The coroner was a forensic pathologist who handled that county’s autopsies. Until the county could find a replacement, Cleveland would have to pick up his cases, even though the office was already pushing NAME’s caseload limit. Like many offices around the country, Cleveland’s borrows pathologists or hires freelancers to come in for a week or two to relieve the staff, but now it would most likely have to hire a new full-time pathologist, which could take years.
“We’re getting to this precipice where we’re not going to have enough people to do the grunt work,” Gilson later told me. “There are eight doctors in my shop. Only one of them is under 50. She’ll be all by herself in 10 years!”
The most obvious cause of the forensic-pathologist shortage is the substantial pay gap between their field and other medical specialties. “Forensic pathologists are some of the lowest-paid physicians in the country,” said John Fudenberg, the coroner of Clark County, Nev., who is not himself a forensic pathologist but leads a team of them. “They go to more school than a lot of medical doctors, and they come out and a lot of them are starting at like $150,000 a year. They could go into clinical pathology and make nearly twice that!” Physicians often leave medical school hundreds of thousands of dollars in debt, which makes it difficult to justify further training in exchange for a lifetime making a fraction of the average physician’s salary.
Most medical schools do not promote or discuss forensic pathology as a possible career path. Last year, only 44 out of 24,399 active residents in subspecialty programs in the U.S. undertook forensic-pathology training. “It wasn’t even an option in medical school,” Todd Barr, a forensic pathologist working under Gilson in Cleveland, told me. “Pathology was barely even taught. I think I had a forensic mind already, back then, but nobody ever said, ‘Hey, you ought to think about forensics.’ And I wish they had.” It took him 13 years of practicing medicine to find his calling in forensics, because he never knew about it.
There’s little consensus about what can be done, beyond better pay, to remedy the shortage. Some suggest forgiving student loans or increasing the number of visas available for forensic pathologists from other countries. A contingent of medical examiners would like to see the coroner system done away with entirely, because it lacks standard qualification requirements. Many sparsely populated counties don’t have the budget or the workload to sustain a trained forensic pathologist. Ross Zumwalt, then the chief medical examiner for New Mexico, told NPR in 2011 that if you die near a state or county line, “the space of a few yards” can determine whether a death is well handled. “On one side of the border,” he said, “you have a statewide medical examiner and competent death investigation; the other side of the border may be a small county coroner with few resources and little training.” Often, coroners in less stringent counties receive very little training in death investigation before beginning their duties. In many places, like the state of Pennsylvania, the only requirements are to be a legal adult with no felony convictions who has lived in the county for one year and to complete a basic training course.
Several people I interviewed pointed to a subtler problem, which may lie at the root of the low salaries and institutional neglect: Americans are suspicious of anyone who deals voluntarily with the dead. Even doctors can be wary of “the gore, the dirtiness of it,” says Elizabeth Mooney, a deputy medical examiner and colleague of Gilson and Barr’s. Forensic pathologists aren’t there to help people “get better,” which subverts the common expectation of a physician’s task. Among physicians, she says, there’s a misimpression that because they don’t deal with living patients, forensic pathologists have an inferior understanding of clinical medicine. A number of doctors told me that the field receives less research funding and support because of the assumption that those dollars would make more impact elsewhere.
In reality, though, spending money on the dead is spending money on the living. In Cleveland, the medical examiner’s office is the first to recognize when a new synthetic opioid hits the streets, and it works closely with the D.E.A., the Postal Service and local law enforcement to identify connected overdoses and the supply chains that cause them. That office helped trace three infant suffocations to a single maternity hospital that treated all the mothers; while nurses told mothers to place babies on their backs to sleep, the nurses themselves frequently placed them on their sides. Several mothers imitated this when they went home, and their babies suffocated overnight. Investigators reached out to the hospital to draw its attention to the problem.
Medical examiners often testify at trials for homicides, domestic violence, drug trafficking, assaults and other lethal crimes. Worrell, who has since moved to the Denver medical examiner’s office, told me the story of a bedridden older man who was neglected and abused until he died, in what she could tell had been torturous conditions (his bed sores had become infested with maggots). The man’s wife and adult children, who were his caretakers, suggested blandly that he died of natural causes. Later, Worrell pulled his social worker’s notes and found years of documentation of his abuse. “I had to take probably a half an hour and sit outside and not do anything,” she said. “I was just like, I can’t — I just — felt so bad for that guy. But then at the same time, one of the greatest parts of our job is that I’m his voice.”
I paused her for a second to ask what that meant. “That’s just my mind-set,” she replied. “I see that, and I’m like: OK, I’m here for you. I’m your voice. I’m going to protect you. All those people that mistreated you and left you there to rot and die? [Expletive] them. We’re gonna get ’em. Me and you, buddy.”
She sat back in her chair and smiled. “And I did. They all pleaded guilty. The whole family got charged.”
Cuyahoga County’s Office of the Medical Examiner has one of the oldest forensic pathology training programs in the country, and several times a year it hosts death-investigation trainings for law enforcement officers, prosecutors and first responders. A few days before taking the training myself, I met Christopher Harris, the office’s communications specialist, outside a warehouse of mock death scenes. A dummy dressed in a hoodie was sprawled under a picnic table on AstroTurf covered in blood, with a pistol near his rubber hand; another dummy in a house dress lay on the floor of a fake kitchen with the oven door open. These sets were built for the final test, in which students assess each scene and make an initial determination.
“You’ll do this on Tuesday, after you take the trainings,” Harris said, guiding me through each room. The idea is that death can fool you if you don’t know what you’re looking at, and despite the garishness of the stiff-limbed dummies, the improbable redness of their blood, the point is made. I mistook a particularly gruesome-looking accident for a homicide and an overdose for a natural death.
On the morning of the first day of the death-investigation training, we received a quiz. The questions ran in this general direction:
Fill in the blank: “A torn gunshot wound that can be put together again is ______________.”
True or false: While processing a hanging scene, the ligature should always be removed from the decedent on scene.
One by one, the pathologists took the lectern. Mooney taught us how to quickly distinguish between a stab wound from a blunt weapon and one from a sharp tip. Another doctor covered drownings; a third, hangings. We learned to recognize the way bullets will stipple the skin while entering the body versus exiting and how the body looks after poisonings, deaths in custody, bludgeonings, car accidents, hypothermia, hyperthermia, fire. We learned to recognize the common forward-slumping position of people who die from opioid overdoses, which is sometimes referred to as prayer position. We learned to look at a corpse and its damage or rot as a story — the last story a person will ever tell, and one he or she needs help communicating.
This work is unpleasant to think about for most people. But Americans’ unwillingness to devote time and money to studying the dead — our supposition that the story, or the parts of it that matter, stop with the heartbeat — absolutely fails to imagine the intimacy with which the living and the dead remain connected. The dead tell us how we’re dying, how we’re living, who among us gets a better shot at a whole and healthy life and the ways in which we remain vulnerable to one another and to the vicissitudes of an unpredictable world. Our epidemics, the commonality of our despair, our continual mistakes, the progress we have yet to make, the wrongs we have yet to correct — all these are mirrored back to us by the dead.
In late 2019, news outlets began reporting on a study commissioned by the Congressional Black Caucus showing that the rate of suicide among black American teenagers was soaring. More than a year had passed since Gilson and I stood near the body of the 13-year-old in his morgue, so I called him to ask how he felt about his warning finally reaching the public consciousness.
He reiterated what he said then: that public-health studies tend to work with data gathered by offices like his a year or more earlier. He wondered whether the government had “missed a time to intervene much sooner.”
As it happens, the newest data in that study was two years old. Information about all the teenage suicides since — including the boy I saw in the Cleveland morgue and many hundreds of others — is still wending its way from medical examiner and coroner’s offices all over the country to the C.D.C., from which it will make its way to policymakers, academic researchers, news outlets and finally teachers and parents. Perhaps it will arrive sometime in 2022. How many more will have died by then is anybody’s guess.
Jordan Kisner is the author of the essay collection “Thin Places.” This article is adapted from that book, which will be published this month by Farrar, Straus & Giroux.