IN FLU SEASONS In the past, James Gill never worried about how bereaved families might receive the death certificates produced by his office. As Connecticut’s chief medical examiner, he oversees investigations into roughly two-thirds of all deaths in the state, and his work is rarely controversial. Covid-19 changed that. Family members sometimes wonder if covid was the cause of their loved one’s death; some want the virus removed from the death certificate. Dr. Gill, a public official, is insulated from such pressure. That is not so in many parts of America.
Death investigation in the United States falls into two broad categories. Medical examiner systems are run by unelected technocrats, doctors who investigate deaths and write certificates. Forensic systems are run by elected officials, who may or may not be medical doctors. Both have the support of forensic pathologists, autopsy specialists.
About 60% of Americans live under medical examiner systems, according to Jeffrey Jentzen, a University of Michigan professor and author of research on the history of death. Coroners dominated during the early years of the republic, but were prone to corruption. Undertakers, law enforcement officials, and insurance agents all stood to gain by taking a second job as a medical examiner. The issuance of death certificates provided many potential avenues for profit, from determining insurance payments to covering up evidence of a crime.
A push to replace coroners with medical examiners gained traction in the early 20th century, before running out of steam. Coroners draw little attention: about 80% ran unopposed in the last election cycle. But polarization has created more competition. When Bobbi Jo O’Neal ran for coroner in Charleston County, South Carolina in 2020, after two decades as a nurse conducting death investigations, she faced a less qualified opponent. Yet as a Republican in an increasingly liberal area, she barely managed to get by.
Covid-19 has put death investigators under pressure. With no national oversight and often minimal guidance from states, they were left to fend for themselves. Carl Schmidt, medical examiner for Wayne County, Michigan, says his office decided that if they didn’t see symptoms of acute respiratory distress, along with an inflammatory response indicating a viral infection, the death would not be attributed to Covid-19. Others were less meticulous. Dr. Schmidt recalls a coroner who made a presentation arguing that performing covid-19 autopsies was unnecessary. The varied quality of autopsies is one reason why measuring excess deaths provides a better overall indicator of the number of Covid victims.
But it is the politicization of the pandemic that has most exposed the weaknesses of forensics in the United States. Coroners relying on Covid-skeptic voters have not been as scrupulous as their medical examiner peers. A coroner in Missouri candidly told the press that he removed Covid-19 from death certificates at the request of the deceased’s family. Despite the growing demand for their services, medical examiners have had difficulty obtaining additional resources. Dr. Schmidt observes that “some autopsies are done in a garage with a single lightbulb, like a Quentin Tarantino movie.”
Excess deaths may be a superior tool for a broad count of covid, but death certificates from autopsies provide critical information for understanding the virus. America’s ability to provide reliable systems will remain patchy and under-resourced. Forensics “were already overwhelmed by the opioid epidemic,” recalls Dr. Gill, “and the cavalry weren’t coming at that time.” ■
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This article appeared in the US section of the print edition under the headline “The Politics of Death.”