Broward County Medical Examiner Dr. Craig Mallak warns of dangerous drug combinations at an opioid epidemic town hall in Pembroke Pines on Aug. 24, 2017. (Photo credit: Peter Haden / WLRN)
By Marsha Mullings, MPH
On March 11, 2020, The World Health Organization declared the coronavirus outbreak a global pandemic. It was the beginning of the end of normality in the lives of Americans. It has only been seven months since this declaration but already we speak nostalgically about our lives “before COVID,” as if they existed in some distant past.
Our present lives are absorbed with our attempts to adjust to this pandemic, while dealing with the reality that we are only just beginning to understand this novel coronavirus and Covid-19 disease. Much of our attention is focused on exposure risks and in the event of infection, the disease progression. We worry about its effects on our bodies, the populations that are most vulnerable to illness, the possibilities of serious illness or death. We are aware of the gravely ill and those who have succumbed to illness, but we are naturally, intensely focused on avoiding illness and remaining alive.
Living though, ultimately results in dying and some deaths, by manner or cause, significance to public health, or other items pursuant to Florida Statue 406, must be investigated by the Office of the Medical Examiner.
This office is charged with, among other things, investigating death and learning about the mechanisms that preceded the end of life. Covid-19 is a disease of significant public health threat and investigation of a resulting death is critical to understanding its manifestations and the manner in which it destroys our bodies.
Dr. Craig Mallak, Chief Medical Examiner at the Broward Medical Examiner Office has to date, reviewed over 1,300 cases of Covid-19 deaths. He describes a daunting task which includes reading lots of medical records, sometimes hundreds of pages for a single case. Collaborating with colleagues is critical.
Extreme care is applied to distinguishing between a Covid-19 death and one in which Covid-19 disease was simply a contributing factor. This involves reviewing the constellation of processes working to fight off infection and deciding whether the destructive effect of these processes on different organs were a primary cause of death or rather, accelerated the death of someone with serious underlying illness.
Besides assigning cause of death, these reviews also highlight local demographic trends that mirror national trends. From his reviews, Dr. Mallak has learned that most of the cases are over thirty, and many are over 60. Blacks and Hispanics are over-represented here as they are nationally. Most of the cases have multiple underlying conditions, as reflected nationally.
Identifying Covid-19 deaths and parsing local demographic trends are important to our understanding of Covid-19 in Broward. More salient though is the important information gleaned about disease management and disease conditions among those alive with Covid-19.
Dr. Mallak describes an untiring effort among medical providers in managing the care of patients, and working, within the bounds of ethical practice, to abide by the wishes of their families.
When asked whether differential access to medical intervention might have been a factor in death, Dr. Mallak replied, “No, when they get really sick, it was really driven by the family how much more intervention they wanted.” He went on to say of the medical care providers, “some families wanted everything right up to the very end…so they keep going. They really tried to follow the family.”
Asked about underlying conditions, a topic of intense focus regarding Covid-19 disease, Dr. Mallak describes the “big three” that he has found in his reviews of death: obesity, diabetes, and kidney disease. Close behind he said, were impaired lung function such as asthma or COPD. Individuals with renal disease were usually at stage three or four.
We are at the beginning of our understanding of the complex disease patterns and manifestations seen among Covid-19 patients and evidenced in their death.
When asked about how information gleaned from reviewing Covid-19 death can serve as lessons for reducing the risk of serious Covid-19 illness, Dr. Mallak was quick to recommend weight loss, healthier eating and exercise, particularly among those diagnosed as prediabetic. He warned, “once you’ve got diabetes, it doesn’t cure itself, and then it’s a relentless attack on your vascular system and on your renal system…” Dr. Mallak has taken a strong position on weight loss as a Covid-19 mitigation practice. Though he was of normal weight, the alarming number of deceased individuals with obesity spurred him to lose a substantial amount of weight in one month.
Dr. Mallak continues to review hundreds of Covid-19 medical records and has a large repository of information regarding Covid-19 disease. They tell of the cascade processes, inflammation, and clotting that are so devastating to every organ system in our bodies. The records tell us that Blacks and Hispanics are disproportionately affected by Covid-19 disease and are overrepresented among those who have succumbed to the disease.
We know already that those with multiple underlying conditions are at a much higher risk of severe illness or death. From these records, we know that three conditions predominate: obesity, renal disease and diabetes.
We have all learned of the extraordinary efforts made by the medical care teams to preserve the life of ill individuals; it is no surprise then, that this is strongly corroborated in reviewing the records of the deceased. Ultimately, much of what we learn about Covid-19 disease and lessons about increasing the odds of survival and restoring health, may come from studies of those individuals who have lost their lives.
