Causes of Death Feature

Nine o'clock in the morning is no time for spiritual reflection in the morgue of the Dade County Medical Examiner Department. The first corpse of the day, a pallid woman with three deep gouges above her right ear, is already in place on an autopsy table and seven others are queued up in the walk-in cooler next door. "This should be an open-and-shut case," says Dr. Roger Mittleman, associate medical examiner, as he quickly loads a scalpel with a fresh blade and drags the instrument across the woman's torso in a Y-shape incision. One cut from each shoulder to the center of her chest, then one sure cut down to her pubis.

"She put a hex on her boyfriend, and when she went to sleep, he hit her three times on the right side of her head with a construction stake," explains Mittleman, a slightly nervous man with a stoop suggestive of his years spent leaning over examination tables. Gripping a pair of industrial-size shears in both hands, he chomps through the ribs along both sides of the corpse's sternum. A phlegmatic morgue technician lifts out the breast plate and folds back the thick flaps of skin and saffron-color fat to reveal the glistening internal organs within.

During the ensuing hour, Mittleman and his attendant technicians empty the corpse of its contents, scooping out the heart, lungs, liver, stomach, pancreas, spleen, kidneys, and, after slicing the skull with a small, electric circular saw shaped like a pizza cutter, the brain. The organs are weighed, then examined on a wooden chopping board, and samples of each are stored in small plastic deli containers for detailed analysis.

The procedure is executed quickly and with little discussion. This morning the gentle sounds of the autopsy - the scrape of a scalpel removing tissue from the skull, the woody knock of a knife against the cutting board, the continual snap of a photographer's camera documenting every stage of the study - are often the only sounds that echo through the sterile, fluorescently lighted morgue.

The process is routine for the doctor and his assistants. It's also necessary - particularly in our litigious society, where any death could develop into a multibillion-dollar lawsuit. "Part of the reason for doing a full autopsy is you never know what's going to become an issue," Mittleman explains. "Even food in her stomach could become an issue. You never know when another cause of death will be proposed. It can happen in pretty obvious cases. And it's my duty to defend what I write on a death certificate."

A detailed autopsy may also offer an explanation for death to a bewildered, bereaving family. "The families themselves have a need to know," says Dr. Joseph Davis, who has served as Dade's chief medical examiner since 1958. "We had a lady today, 101 years of age, who died peacefully at home, but one month after a car crash. The family was very interested in finding out what happened. What was the relationship between the death and the auto accident, if any? Or between the death and the medical care she had subsequent to the accident, if any?" To ascertain what happened, Davis says, he had to study the woman's medical history carefully. And open her up.

Aside from allaying legal concerns and providing, literally, a sense of closure, a medical examiner's slicing and dicing can bear directly on the way people live their lives. Autopsies often uncover medical secrets, spurring improvements to public health. "We're finding disease processes that haven't been recognized," says Davis. "We come up with information that is useful in diagnosis and treatments."

The Medical Examiner Department receives every body that expires suddenly or unexpectedly in Dade, including all the homicides, suicides, and accidental deaths. In most of the other cases, a doctor determines a cause of death without having to call in the medical examiners. "If there's no doctor to sign," Mittleman says, "or if for some reason there's a problem, like the family is so emotionally distraught they don't know what to do, then the body may come here and we decide what to do." In all, 18,136 people died in Dade County in 1990. The medical examiners inspected 3637 bodies, determining that about 60 percent of them had died "natural" deaths. A ticket to the county morgue, however, doesn't guarantee you'll receive one of the medical examiner's full-service autopsies. Only 70 percent of the bodies rolled in each year are actually gutted; the remainder simply receive an external once-over.

Autopsied or not, no death in Florida theoretically escapes the state's official computer maw. All death certificates are sent to the state health department, where drones shovel them into enormous number-crunching machines. "We're pretty understaffed right now," moans Felipe Lorenzo-Luaces, a feeble-voiced researcher, from deep within the Office of Vital Statistics at the state Department of Health and Rehabilitative Services. "There used to be seven statisticians. Now we're down to one." Lorenzo-Luaces and his skeleton crew are in the process of compiling the tables for the forthcoming 1990 edition of Florida Vital Statistics, an annual volume that documents, among other things, who perishes of what in the Sunshine State.

"If you're looking at how many different ways there are to killing yourself or dying," muses Lorenzo-Luaces, "there are probably an infinite number of ways." Perhaps. But HRS has, in its infinite administrative wisdom, designed a rigid classification system that assigns each fatality to one of 68 cause-of-death categories, which are further broken down into 360 categories. "The 360-cause-group listing is very detailed. Are you sure you want that listing?" asks a helpful Lorenzo-Luaces, an anomaly the HRS Bureaucratic Mean Police haven't yet ferreted out. "We use the 68-causes-of-death listing because it's a lot easier to work with. It's a condensed version, and we can pick our ten leading causes of death from it."

And indeed, the 360-cause-group listing is much more specific than its simpler-minded relative, the 68-cause-group listing. "Maternal causes" on the short list becomes a dozen separate causes on the longer list, including "legally induced abortion" and "indirect obstetric causes." But you're out of luck if you died of some esoteric accidental cause - say, bleeding to death after being sliced by a Cuisinart blade while preparing quiche Lorraine - and hoped for an equally exotic cause group. The best you could expect is to be filed under "Accident: Machinery."

"Vital Statistics is inherently inaccurate, based on a number of things," says Chief Medical Examiner Davis. "One is the coding rule that [HRS] can only include one cause of death. But when you have a multifactoral death causation, many of those factors are left out." By way of example, Davis imagines a drug-induced brain hemorrhage. "The `natural' cause - bleeding - would be listed in part one of the death certificate, and the `contributory' cause - drugs - would be listed in part two," says Davis. "The Office of Vital Statistics would pick only the first one, and here we are dealing with two causes working in concert." However HRS isn't the only party to blame for the misleading statistics. According to Davis, many doctors - precisely those people who are authorized to declare the end of a life - don't have a clue how to code or report deaths properly.

Despite their inaccuracy, the HRS stats are widely used in the public health industry. They inform the planning of medical facilities, help insurance agencies derive actuarial tables, and highlight general health and disease patterns. "They are used by people that want to know, generally, where the problems are," Davis explains. "In the long run, the inaccuracies tend to smooth out when you get into bigger numbers. If you don't try to make the diagnoses too specific, the numbers can be very useful. If you try to draw too much specific data, then you get into trouble."

The concepts of public health care and statistics have developed simultaneously; both trace their genesis to the Middle Ages. "The public-health concept began with the prevention of the spread of plagues," says Davis. "Part of prevention was the documentation of what was going on. With AIDS, we're right back where we were with the great plagues. We don't know what to do about it. We don't know where it came from. The least we can do is document it."

And Dade County provides plenty of documentable AIDS activity. According to HRS statistics, the human immunodeficiency virus (HIV) is more active in Dade than anywhere else in the state. In 1990, about a third (710) of Florida's total HIV-related deaths occurred in Dade. The bulk of the county's AIDS victims, as in other major urban areas around the nation, are between the ages of 25 and 64, with a majority in their 30s and early 40s. More than half are white males, about a third are black men, and most of the remainder are black women.

Dr. Margaret Fischl, director of the Comprehensive AIDS Program at the University of Miami, attributes the county's high HIV rate in part to the city's multiethnic composition and the regular flow of people to and from foreign countries. And because the principal mode of HIV transmission overseas is between heterosexuals, the virus has infiltrated the Dade heterosexual population in extraordinarily high numbers. In fact, according to a national study in 1990, Dade County has the second-highest rate of heterosexually transmitted HIV cases in the U.S., as well as one of the highest general HIV rates.

Part Two
However, Fischl doubts heterosexuals, by and large, will grasp the wisdom in the statistics and change their sexual habits anytime soon. "I don't think heterosexuals think they're at risk yet," she says. "We're seeing men and women who are sexually active and have no idea they're at risk." Fearless heterosexuals, Fischl says, generally have a greater number of sexual partners and avoid condoms as most people would goldfish consumption. As a result, public health officials expect Dade's AIDS rates to skyrocket during the next decade.

While AIDS might provide the most obvious and headline-grabbing example, Dade's entire hit parade of fatality reveals that how we live is how we die. Throughout the HRS statistical breakdown, the quartet of cigarettes, alcohol, drugs, and a poor diet wreaks its havoc:

* Tobacco almost entirely accounts for the chronic obstructive-lung-disease deaths (592 in 1990), Davis says, and contributes in part to the heart-disease and cancer statistics.

* A poor diet boosts the cancer and heart-disease numbers, and, especially, the stroke statistics.

* Alcohol courses freely through all the figures. "It can cause lung disease, liver disease, and heart disease," Davis says. "It can affect behavior and make people drive cars into trees and into canals. Forty percent of all homicides have alcohol aboard, 35 percent of suicides have alcohol aboard, and 60 percent of motor vehicle accidents are alcohol-related."

* The influence of drugs, too, is widespread. Bill Wilbanks, a professor of criminal justice at Florida International University, estimates that about a quarter of all Dade homicides are drug-related. The Dade medical examiners say many homicide victims test positive for illegal drugs, particularly crack cocaine. Drugs have also precipitated many natural deaths, from brain hemorrhage to heart failure, and have spared no age group. "Some of the perinatal fatalities are associated with drug abuse," says Dr. Eleni Sfakianaki, medical executive director of the Dade County Public Health Unit. "We find that many women using cocaine and crack, often at the same time, give birth to infants exposed to drugs in utero." HRS attributes 29 of Dade's accidental deaths to drugs, but medical examiners say illegal substances are responsible for a considerably higher number of fatalities.

In recent years, Dade County residents have taken some of these statistics to heart. Largely because of improved lifestyles and health consciousness, medical officials say, the rate of deaths attributable to heart or liver disease and stroke have dropped significantly in the past decade. Nonetheless, according to HRS statistics, the leading causes of death have not changed much from the late Seventies, and the top three killers in the state a dozen years ago are the top three killers in the state today.

Suicide rates have remained fairly constant, as well, both in Dade and statewide. As Chief Medical Examiner Davis puts it, "Suicide keeps marching on and on and on." While the number of suicides usually corresponds to the size of the population, he explains, the homicide rate reflects the dynamics within a population, such as drugs and economic discontent. In a statistically ideal world, Davis says, the suicide rate would be higher than the homicide rate. That is the case statewide, but Dade County produces more homicides than suicides and accounts for more than a quarter of all homicides in Florida.

That was not always the case, according to Davis. As recently as the Sixties, suicides exceeded homicides on the Dade death charts, but by the Eighties homicides surpassed suicides, with the peak of the killing curve in 1980 and 1981 at the height of the Mariel boatlift. Since then numbers have dropped generally, although homicide has continued to demonstrate a voracious appetite for a section of the population: young black males.

However homicide, like any other cause of death, does not always pick and choose by race or gender. Consider Dr. Mittleman's early-morning autopsy subject. It seems pretty clear what killed the 34-year-old woman: Her boyfriend had already admitted his culpability to a counselor, and his weapon of choice - a rusted, three-foot construction spike - fit the wounds perfectly. So why the autopsy? You can never be too sure, Mittleman explains. "What if I found nails in her stomach? What if he had forced her to eat nails?" the experienced pathologist posits. "No, that's a little far-fetched. How about if something was stuck in her rectum? What if a knife had been stuck all the way up her rectum, so far that you couldn't see it from the outside? Then obviously the boyfriend's lying and then the police would have to interview him again."

But the autopsy reveals nothing that would contradict the boyfriend's story, and Mittleman writes "blunt cranial trauma" as the cause of death on the murdered woman's death certificate. The corpse, out of the cooler for an hour and a half, has begun to turn a light shade of purple, an unmistakable outward sign of the inevitable decomposition. On deck are two more bodies: a 74-year-old man who threw himself into a pool with two household steam irons tied to his leg, and a three-month-old baby who died of sudden infant death syndrome. The lab technicians begin the quick procedure of restoring the body to some semblance of its former self and returning it to the cooler until it can be taken to a funeral home for embalming.

A lab assistant puts the woman's vital organs into a plastic bag, stuffs the package into the corpse's gutted torso, and, using thick cotton string, quickly begins suturing the incisions. "She can be put back together," Mittleman says, almost reassuringly. "It's not as bad as it looks.


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