Texas Doesn't Keep Track of Deaths Very Well, and It’s Affecting Public Policy.
Bill Gravell keeps a pair of camouflage boots in the backseat of his white pickup truck. They've been through pastures and farmlands, in the middle of plane and train crashes, he says.
Once, Gravell didn't chance to change out of dress shoes on his way to a body and ended up ruining those shoes. Now, he makes ready at a moment's notice.
Gravell is a Williamson County Justice of the Peace (JP). On the bench, he handles things like misdemeanors, property seizures and small claims. Off the bench, he has some bigger tasks. He signs arrest warrants and marries people. He also investigates how people die.
“Out of all that I do I feel like the death inquests and the death investigation is the most important matter that I deal with,” he says. “I often tell families that the reason I am here is because I am writing the last chapter of your loved one’s life.”
In much of the state, when someone dies outside of a doctor’s care – in an accident or in their house – someone like Gravell is called to the scene.
By law, cities with more than a million people are required to have a medical examiner, but in smaller cities, the work of death inquests falls to JPs.
"I often tell families that the reason I am here is because I am writing the last chapter of your loved one's life."
There are hundreds of JPs in Texas and, when it falls to some of them to do a death inquest, Gravell says their job is to be a second set of eyes.
“The role of the justice of the peace is to determine the cause and the manner of death,” Gravell explains. “I use a lot of tools to help me do that. I do use the detective reports. I use patrol reports. I use video evidence. I also look at the deceased and determine if there is enough information there to determine a final cause and manner of death and, if not, I order an autopsy.”
This is how information about how people die makes it into many death certificates in the state. Gravell says he does about 12 to 15 of these a month.
Death certificates are obviously important. They allow families of the deceased to close bank accounts, collect life insurance and, Gravell says, deal with death in a practical sense.
However, that information also helps officials keep track of what could be leading to preventable deaths, and the way Texas gets that information is inconsistent.
There are a lot of reasons for this. One reason is because the difference between a medical examiner and a JP is pretty big to begin with.
“To be a board certified forensic pathologist, which is what we call a medical examiner, you have a medical degree, then you have to go through a pathology residency, then you have to go through a special residency,” says Chief Administrative Officer for the Travis County Medical Examiner’s Office Sarah Scott. “So, that’s quite a bit of education. In contrast, a justice of the peace has no formal education requirements in Texas, and that’s not to say that many of them don’t do an excellent job.”
Scott says there are some standards, of course. For example, the cause of death can’t be something that doesn’t actually kill someone. An investigator has to point to things like a disease or traumatic injury as cause.
“But how you arrange to arrive at that conclusion is very different among different individuals who practice the investigation of death,” Scott says.
Even the way medical examiners do their jobs can vary because they aren’t regulated by a state agency. And regulation and education aside, when it comes to JPs, Gravell says money is the sometimes a biggest driver in how they do their job.
“Part of the stress and pressures that we face as a justice of the peace is, when you order an autopsy, it is not an inexpensive thing,” Gravell says. “In our community, I order an autopsy based upon the need and to determine how to best determine the cause of death. I never calculate the cost to my county.”
But that’s not the case for all JPs, he says.
“Some of our judges in other parts of Texas really struggle with their commissioners courts and their county judges being accused of spending money excessively,” Gravell explains. “And I appreciate and respect those elected officials’ opinions, but the truth is, when I’m writing the last chapter of that person’s life, I have to do it right.”
And getting it right means Texas has a better picture of what is happening in the state when we consider things like public health policies.
A good example of what happens when numbers don’t paint a good picture of what’s actually happening is with opioid overdoses.
Mark Kinzly’s life’s work is finding for help for people dependent on opioids like heroin and pain killers. He runs a statewide program that gets a life-saving drug called Naloxone into the hands of people across the state.
Kinzly says overdoses are a big problem here. He says state health officials need to be more aggressive about dealing with the problem, but those deaths are undercounted here.
“If you were to look at the number of fatalities in the state of Texas, you would say, 'Okay, this is not a priority,'" he says. “But all the national leaders around health care... look at the state of Texas, and the Southwest here, and will absolutely tell you that this is a huge problem in the state of Texas.”
Gravell says a lack of information on this specific problem could be due to the fact that there aren’t enough toxicology panels ordered in some parts of the state.
"If we are reporting bad data around deaths, we are probably also reporting bad data around a number of other health consequences."
“If you are not ordering the toxicology, it’s probably because you haven’t ordered the autopsy," he says. “If judges aren’t ordering autopsies, it could be that they are receiving pressure from others not to spend those funds."
That, Kinzly says, is making it harder for him to ask lawmakers for help.
“I, personally, hear about [overdoses] on a daily basis, and then when we go to the Capitol and we see that the legislators – who are really trying to do the right thing in regards to the health and well-being of the citizens of Texas, you know – are misinformed,” he says. “If we are reporting bad data around deaths, we are probably also reporting bad data around a number of other health consequences.”
It’s not hard to find examples of that, either.
A recent study found the state’s maternal mortality rate doubled in 2011 and 2012, and no one really knows why.
Last month, a statewide task force released a report about pregnancy-related deaths, and researchers said one of the biggest issues they faced while looking into these deaths was that the way in which were reported and recorded was inconsistent, making it hard to explain what’s going on.
Scott says there are solutions out there, though.
Florida, for example, has a regionalized medical examiner system, which, she says, would be a step up.
Lawmakers could also consider reimbursing counties for the autopsies ordered. Of course, all of this would require state spending, which could be a tough pitch in the next legislative session.
“Putting into effect any kind of infrastructure has a certain amount of expense, but you have to understand that the ultimate good outweighs the initial expense,” Scott says. “If you have better information, you are obviously able to make better decision about health policy.”