In the months before his county’s morgue neared capacity, before he started wearing his face shield and “moon suit” to answer calls in neighbors’ homes, and before his own coronavirus diagnosis got him admitted to the hospital, Coahoma County, Mississippi, coroner Scotty Meredith knew this summer was going to be the worst in his three decades on the job.
On April 3, as COVID-19 deaths in Mississippi hovered in the low double-digits, the state’s chief medical examiner, Mark LeVaughn, fired off a letter to Meredith and the state’s 80 other coroners. State law outlines a simple procedure for investigating deaths outside a hospital: the coroner collects evidence at the scene, then sends the body to a medical examiner in Jackson for autopsy. But the gist of the ME's letter, obtained by The Daily Beast, was that when it came to deaths from COVID-19, coroners were on their own.
For years now, the severely understaffed state medical examiner’s office has struggled to handle all of the deaths in Mississippi. Doing so has often meant shifting more of the burden for handling deaths onto county coroners, who, unlike medical examiners, usually don’t have a medical degree and cannot perform autopsies.
The problem with being shut out from the medical examiner’s office, as Meredith explained, “is not just that they’re not taking the cases, but there’s not any guidance” for what to do with a suspected coronavirus case. Several coroners said they’ve begun rationing supplies, like test kits, echoing supply-chain woes in other hard-hit states since the early days of the pandemic that experts generally believe have deflated the COVID-19 death count.
But in Mississippi, the bodies are piling up fast.
“My morgue was completely full all last week,” Panola County Coroner Gracie Gulledge told The Daily Beast. “It’s bad. We’ve only had our cooler full once or twice in the whole time I’ve been in operation, and it’s been 14 years.”
Over the last few weeks, Mississippi has emerged as something of a worst-case scenario in the country’s coronavirus landscape: an already poor, sick, medically under-resourced state where both infections and deaths are rising faster than almost anywhere.
Last week, 200 Mississippians died from coronavirus, the second highest rate per capita in the country behind Arizona, according to data from Johns Hopkins University. But infectious disease experts say that the lack of standardization and resources among coroners, combined with Mississippi’s longstanding health disparities, means the death rate there is likely even higher. Although undercounting is a problem nationally, in a state like Mississippi, where resources are scarce and state leaders have been hesitant to impose mask regulations or scale back reopening, it could be a full-blown crisis.
“If the coroners don’t have the resources to pursue the diagnosis or the potential diagnosis of COVID-19 in many of these unattended deaths, then that will undoubtedly lead to an undercount of the actual fatal impact of this pandemic virus,” said Dr. William Schaffner, a professor of preventive medicine and infectious disease at Vanderbilt University Medical Center in Nashville.
And an accurate picture, he said, is essential for an accurate response.
“From a public health perspective, you would like to define the extent of the outbreak as carefully as possible,” Schaffner said. “You make all these policy decisions and we hope they are informed with the best possible data.”
Sean Tindell, the commissioner of the Mississippi Department of Public Safety, which oversees the medical examiner’s office, said the policy of not assisting with coronavirus investigations may need to be reexamined.
“I know that some stuff was sent out to the coroners before I got there as it pertained to how to handle situations of the coronavirus,” said Tindell, who was appointed to head the agency in May, a month after the first letter was sent. “And it might be important for us to reevaluate some of the information previously provided.”
The Mississippi Department of Health said in a statement that coroners can request test kits through their county Emergency Management Association, though multiple coroners canvassed by The Daily Beast said the supplies did not always arrive. Department of Health spokesperson Liz Sharlot also said that the CDC website has guidance on conducting nasal swabs and that while the department could hold training sessions, counties have not requested it.
“We are always worried about details and count numbers,” Sharlot told The Daily Beast.
The office of Mississippi Gov. Tate Reeves did not immediately respond to requests for comment.
Mississippi coroners got a second letter from the medical examiner in June. Several autopsy techs had resigned and the already barebones staff was now down to just two medical examiners and a single tech statewide. When it came to the 1,500 autopsies that the state was still performing each year—mostly accidents and homicides—coroners should expect delays, often three weeks or more before the body could be sent to Jackson. In the meantime, the counties would need to find a place to hold the bodies.
Under normal circumstances, a delay this severe would cause, in the words of Gulledge, “a bottleneck of bodies.” But with coronavirus cases, hospitalizations, and deaths all surging in the state, it’s nothing short of a disaster. Bolivar County, where Rudy Seals is the coroner, has begun storing bodies in Panola County’s refrigeration unit. Gulledge said she’s hoping Panola County’s board of supervisors will approve another unit like that one; she said that Hinds County, home to Jackson, the state capital and biggest city, has ordered a unit, and Vicksburg has one on order, too.
“This is not getting any better any time soon,” she told The Daily Beast. “If the deaths increase, we’re going to be in trouble.”
The deaths are very likely to increase. The state had just over 9,000 new infections last week, making it virtually tied with Florida for the country’s highest per capita rate of new cases.
“All of these things follow each other,” said Dr. Alan Jones, the clinical response leader for COVID-19 at the University of Mississippi Medical Center. “Hospitalizations are going to follow the positive case rates and deaths are going to follow the hospitalizations. And it’s all a two to three week lag. So we’ll see deaths rise before we see them drop.”
Few states were less prepared to weather a pandemic of this magnitude than Mississippi. This state has fewer doctors per capita than any other in the country, making it harder for people to get to treatment or testing. Mississippi also leads in co-morbidities, from obesity to diabetes and heart disease, that can make someone sicker from coronavirus. These issues, Schaffner said, increase the likelihood that the actual death toll from coronavirus is much higher than the story official numbers are telling. If people can’t get tested while alive, he said, it makes the need for post-mortem testing even more important, especially in a state like Mississippi.
“There’s an under appreciation of how extensive COVID is, especially in these rural areas,” Schaffner said.
In Washington County, coroner Methel Johnson said she’d normally have around 30 calls in a month. But on Wednesday night alone, her office responded to six different deaths. In Panola County, Gulledge estimated she was getting almost double the calls she normally would. And, she pointed out, these calls don’t even represent everyone in the county who is dying. Coroners only respond to deaths when they happen outside a hospital. Within their walls, doctors are the ones who sign off on death certificates.
“You do have an increase in the elderly who are passing away, say, faster than they should,” said Seals, the coroner in Bolivar County. Seals said that if someone had received a positive test for COVID prior to death, that would be enough of a reason to mark it on a death certificate. A recent high fever might be a reason to give a test, as would recent contact with someone who had tested positive themselves. But other symptoms, especially in someone elderly or otherwise unhealthy, aren’t enough of a reason. Tests in Bolivar County, he said, have been very hard to come by.
“If you don’t have any red flags, you don’t swab,” he told The Daily Beast.
“I’m not a doctor, man. I’m a coroner,” he added. “It’s not up to me to say ‘this pneumonia was caused by COVID’ if it wasn’t. So writing COVID when I don’t know for sure, that could be false information and drive the numbers up higher than we already know they are. I would love to talk to someone at CDC or elsewhere who could give me guidance on that. But that’s not a choice I would make until I’m instructed to do otherwise.”
Acknowledging staffing issues in the state medical examiner’s office, Tindell said he’d begun focusing on recruiting his first day on the job.
“From my perspective what we’re trying to do in the medical examiner’s office is look at what needs to be done, make strategic improvements, and try to create a better situation,” Tindell said.
To run for county coroner, Mississippi only requires residents have a high school diploma. Equally important and significantly more rare, however, is that they are comfortable with death. As a result, the day jobs of many Mississippi coroners tread in similar territory. Gulledge is a paramedic. Meredith runs a funeral home.
But 10 days into his own battle with coronavirus, Meredith admitted that after seeing it take others' lives dozens of times, he was now afraid for his own.
“I used to say I wasn't scared of the coronavirus, but I respected it,” he said, in between jagged breaths. “Well, now I'm scared of it and I respect it.”