The COVID-19 death toll in the U.S. has surpassed 700,000. That number is hard to put into perspective, but it exceeds the combined number of U.S. lives lost in combat in World War I, World War II, the Korean War, the Vietnam War, and the wars in Afghanistan and Iraq. Added to that, there were substantial increases in drug overdose deaths and homicides in 2020, with increases continuing in 2021. Overall, the Centers for Disease Control and Prevention reported a 15.9% increase in the country’s estimated age-adjusted mortality rate in 2020.
The volume of life lost in the U.S. has revealed a foundational weakness in our nation’s death investigation system – a key resource within our public health infrastructure. Data, especially data about death, is key to understanding, developing, testing and scaling interventions to protect the health of our nation. Yet we invest relatively little in this crucial information infrastructure. Meanwhile, there is a national workforce shortage of forensic pathology experts, which has resulted in punishing workloads, huge backlogs of cases and, most importantly, delayed and lost information that could be used to save lives.
The existing coroner or medical examiner system is piecemeal at best. Each state can do its own thing, and in some states, there is little standardization across counties in terms of collection and reporting of data, while meager standards may exist for deciding when to perform an autopsy. Criteria for when toxicology tests are required and what substances will be tested for vary across jurisdictions. Requirements related to death investigations also can vary, and some locations do not have adequate resources to deploy crucial forensic tools. Practices for ruling a death undetermined or unintentional also can differ from state to state and even within a state, making it difficult to truly understand these deaths.
Funding for autopsies, toxicology testing and evidence processing is inadequate and getting tighter as the mortality rate increases. Some states require each county to finance its own coroner’s office needs. Yet some of the counties experiencing the highest rates of death from causes like COVID-19, overdose and homicide have fewer resources than those with a lighter burden, since these causes of death disproportionately affect low-income communities. At the same time, some jurisdictions have medical examiners or trained coroners who are appointed to the post. Other areas have minimal training requirements, and the position of coroner is an elected one.
Despite these challenges, the forensic professionals I have encountered in my injury and violence research are doing the best they can in very trying circumstances. I also have the opportunity to work with public health surveillance systems that collect data on two preventable causes of premature death: drug overdose and violence (primarily homicide and suicide). The CDC’s National Violent Death Reporting System and the State Unintentional Drug Overdose Reporting System have made great strides in aggregating detailed information on these types of deaths to inform prevention.
However, these systems are only as good as the death investigation infrastructure upon which they are based. We as a nation need investment in this infrastructure to inform the development of evidence-based and robust public health protections. Only with insight into the circumstances surrounding death can we make progress toward reversing the increase in mortality rates, which itself is crucial to undoing the decline in U.S. life expectancy.
To do this, we need to focus on workforce development for forensic professionals, career-placement incentives to help people work in underserved areas, and national funding for death investigations and toxicology testing that are tied to uniform standards and community needs. Access to timely and high-quality forensic laboratory services and resources to seed public health research that can help prevent premature death also are crucial.
To be sure, there are many unmet needs in our country today. But support of a national death investigation system to strengthen our nation’s public health should be a high priority.