Helping the Living by Learning From the Dead Forensic Investigation Impacts Public Policy to Save Lives
March 27, 2024
In 1993, Dr. Gregory McDonald had one of the most horrific experiences of his career—helping investigate more than
110 heat-related deaths over a span of 10 days—the result of a July heatwave that
had gripped Philadelphia.
McDonald, who currently serves as dean of PCOM’s School of Health Sciences and as director of the MS in Forensic Medicine program, was working at the Philadelphia Medical Examiner's Office (MEO) at the time. The
deaths were well in excess of the typical number of homicides, suicides and other
fatalities that would be expected during a comparable time period. He likened the
death toll to a mass casualty situation.
“You can imagine that a plane crash in which 110 people died would certainly get the
attention of people,” he said.
For McDonald and his fellow investigators at the Philadelphia MEO, the particularly
attention-grabbing aspect was that many of the deaths may have been preventable.
Identifying a Public Health Issue
When assessing the impact of excessive heat or a heatwave, the number of deaths attributable
to hyperthermia is a key indicator. An unusual element of the heatwave of 1993 was
that most of the heat-related deaths did not meet the strict criteria of clinical
hyperthermia. Hyperthermia, McDonald explained, occurs when the body’s temperature
exceeds 104 degrees Fahrenheit. It can encompass a range of symptoms including muscle
cramps, fatigue, dizziness, mental confusion, organ failure and more.
Key Points
Forensic investigations uncover critical insights into public health crises, such
as the identification of preventable deaths during heatwaves.
By analyzing factors contributing to fatalities, forensic investigators highlight
vulnerabilities within populations, such as the elderly's susceptibility to extreme
temperatures.
Classification challenges underscore the importance of refining criteria to accurately
attribute deaths, enabling targeted public health interventions.
Forensic investigations inform evidence-based strategies that safeguard community
health, demonstrating the indispensable role of medical examiners and coroners in
protecting public well-being.
“There’s a spectrum of how these progress,” he said.
When a person is observed with symptoms of heat-related illnesses, medical intervention
may prevent adverse outcomes. For individuals living alone, help may not be readily
available.
According to McDonald, the elderly are particularly at risk.
“They lack some of the thermoregulatory factors that can tell them when they're getting
too hot,” he said. “By the time they realize it, they’re already compromised.”
Many of the heatwave victims were found several days after they died and had other
commonalities—advanced age, preexisting medical conditions and lack of access to a
adequately cooled environment. Several of the victims lived in row homes.
“I grew up in a row home in Philadelphia and literally it's like an oven,” McDonald
said.
Inside temperatures can get very high due to the black tar roofs and lack of cross
ventilation. Oftentimes, there is little or no shade. In more dangerous parts of the
city, residents may keep the windows closed in an attempt to prevent criminal activity.
For the elderly—especially those on fixed incomes—this can be very dangerous.
“Maybe they can't afford air conditioning,” he said. “Even fans, they help move some
air around but sometimes it just makes a convection oven. So then you have people,
they can't get out. They can't hydrate. they start to lose electrolytes, especially
if they're shut-ins or there's not someone checking on them.”
McDonald and other investigators from the Philadelphia MEO made note of numerous other
factors that could have contributed to the deaths including medication use, obesity
and alcohol consumption.
“All those things together can be very difficult to deal with, especially for a compromised
population,” he said. “But again, most of those did not meet these strict criteria
of hyperthermia.”
Unsung Heroes
From a public health perspective, not being able to attribute the deaths to hyperthermia
was a problem.
“In forensics, when you list an environmental condition, like cold or heat, that takes
it out of the realm of a natural death and puts it into the category of an unnatural
death,” he said. That information is added to the death certificate and can give public
health officials hard data they can use to enact preventative measures.
The forensic investigators at the Philadelphia MEO realized they needed to categorize
the heat-related deaths in a way that better highlighted the risk posed by extreme
heat. By studying the excess deaths during the heatwave, they were able to determine
demographic characteristics and validate the criteria they used to classify a death
as heat-related. The findings, published in The American Journal of Forensic Medicine and Pathology, listed the criteria for classifying a death as heat-related as including “a frail,
elderly decedent with or without known preexisting disease or a younger decedent with
evidence of preexisting acute or chronic illness and substantial environmental or
circumstantial evidence of heat as a contributing factor to death (i.e., the decedent
is found in a hot environment without cooling devices, and with windows closed).”
As a result of the work done by McDonald and other death investigators at the Philadelphia
MEO, public health measures were put in place to help prevent future heat-related
deaths. These measures included efforts to increase public awareness about the dangers
of excessive heat and providing susceptible populations with access to shelters or
other air-conditioned locations. In the mid-90s, McDonald was part of a task force
that used data collected on death certificates to identify populations to proactively
reach out to in the event of a heatwave.
This, McDonald explained, is just one example of the important role medical examiners
and coroners play in improving public health.
“We’re the unsung heroes,” he said. “People have a perception of us that we only deal
with dead people, that we have no impact on the living and I do think that’s a mistake.
We’re not only a voice for the dead, we can help the living as well.”