The Science and Politics of Life and Death

Hamilton County Coroner Lakshmi Sammarco on the new crime lab, the opioid epidemic, and Otto Warmbier.

The Hamilton County Coroner’s Office has a preternatural quality baked into it—the type of place where it’s not all that strange to hear someone buzz in at the front door and announce “I’m here for the body,” or where stepping off the third floor elevator smells like stepping onto Willie Nelson’s tour bus thanks to pounds of marijuana evidence drying in the adjoining boiler room.

Hamilton County Coroner Lakshmi Sammarco in the current crime lab in Corryville.

Photograph by Aaron M. Conway

It’s also kind of a dump. That boiler room hot box in the third-floor crime lab is as forced as it is innovative—there’s nowhere else to store the stuff. The hallways are crammed with office overflow. There are two windows to the outside world. “Right now, our scientists’ computers sit right next to their labs, which is dangerous for all sorts of reasons,” says Hamilton County Coroner Lakshmi Sammarco, MD. Her tone is more chipper than in years past, however—county officials broke ground in December on a new $55 million, 85,000-square-foot state-of-the-art crime lab at Summit Park in Blue Ash. It’s something Sammarco has been pushing for since she took office in 2012, a stint in which the often brightly clad and always candid radiologist has found herself at the center of our region’s most noteworthy conflicts. So far, she’s been up to the challenge.

What does the job of coroner entail? Most people seem to think the office just does autopsies.
I don’t personally do autopsies, because I’m not a forensic pathologist. I’m a neuroradiologist. In Ohio, the requirement to be county coroner is that you’re a physician who’s licensed to practice medicine in Ohio and been in practice for two years. We have four forensic pathologists here who do all the autopsies.

So where do you enter that process?
As long as you can say cause of death and manner of death, you’ve done your job as a coroner. The forensic pathologists gather information—toxicology is always done on our autopsies—and then our investigators go to the crime scene, gather info from law enforcement, help us gather situational information, and then we piece it all together as a group and decide if we can determine cause and manner of death. And not in every case can we do that. There are cases where cause of death is undetermined—what if you have 12 or 14 causes, but there isn’t one or two things? There’s no limit, but certainly you want to be able to focus. As far as manner of death, you have homicide, suicide, natural, accidental. If it’s not one of those first four, it’s “unknown” or “undetermined.”

This is an elected position, but you don’t come off as someone who is all that interested in the politics of the job. Is that dynamic difficult to balance?
Before I took the position, I was one of those people saying, “Why do we elect our coroners?” And then I found out within the first three months. As an elected official, I’m accountable to the 900,000 people in Hamilton County to do the job the best I can. I’m not appointed by a small group of people who hold power over me. I’m not beholden to anyone. I realized, if I were appointed by one of those people, I would probably feel a tremendous amount of pressure.

The new county crime lab is finally in the works. Why is that such an important piece to this operation?
We interface with a lot of other law enforcement jurisdictions in the region. Just on autopsies alone, we’re serving three counties in Indiana and five in Ohio, and recently we had Northern Kentucky asking if we could take on some of their cases. At the moment, we just can’t. The crime lab is similar because we’re a regional crime lab—we serve all of southwest Ohio and parts of Indiana. We have 26 scientists now who work in the different sections: firearms, trace evidence, DNA, drugs, and toxicology. There are a lot of different things they’re doing, and my job is not only to advocate for them, because they’re amazing, but also to make sure they have the tools and equipment they need to adequately do their job. In the end, the answers they get make it possible for law enforcement to do their job and keep us safe. Anymore, with the CSI effect, a jury is expecting to get forensic evidence presented to them. The demands on the crime lab are increasing.

Rendering of the forthcoming crime lab in Blue Ash.

Photograph courtesy Hamilton County Coroner

The chief perpetrator of those increasing demands has been the region’s opioid epidemic. In 2012, Hamilton County had 204 overdose deaths; by 2015, the number had jumped to 414. Sammarco and the coroner’s office have played a significant role in identifying the various strains of heroin and synthetic analogs such as fentanyl and carfentanil, pushing for increased distribution of opioid-blocking drugs such as Narcan, and aiding the Hamilton County Heroin Task Force’s efforts to fight the issue on the supply side.

“We only had 403 OD deaths in 2016—‘only’—but I think that’s a reflection of our successful campaign to get Narcan into the hands of first responders,” says Sammarco. “The problem then becomes once you’ve saved somebody, revived somebody, what do you do with them? Or what do they allow you to do with them?”

When did you realize the opioid epidemic was going to command so much of your attention and resources?
We saw heroin in 2012, and we saw a rising number of heroin deaths in 2013. And we noticed we had a couple deaths where fentanyl was present, and we were scratching our heads wondering where they got this stuff from—the fentanyl I’m familiar with is the pharmaceutical stuff. So [in 2013] I got this phone call from the office about an OD in Clifton, and they said, “We think you know this guy.” You know that feeling you get where your heart skips a beat and you get chills down your spine? They told me the name and I said, “There’s no frickin’ way, check it again.” They checked it three times before they called me.

Why was this person such a shock?
He was an Indian kid. I grew up with him, though he’s a lot younger than I am. He’s a college graduate, an accomplished person, and I knew his family. I never would have imagined. He was found in his home with a needle in his arm. It really hit me that this is a problem across the board. All of those stereotypes are just blown to hell. How the hell did this kid end up on street drugs? And when we analyzed him, it was fentanyl. Zero heroin. I’m sure he thought he was buying heroin, and with fentanyl being 100 times more potent—that’s what we were seeing a lot of, people dying accidentally because they thought they were getting heroin. Then a year later we had more and more and our death numbers were going up.

Rendering of the forthcoming crime lab in Blue Ash.

Photograph courtesy Hamilton County Coroner

A local police task force was created to go after the dealers, and there’s obviously been a lot of attention on the treatment side of things. Do you feel the prevention route is still a viable one? There seems to be some fear that the issue has gotten too big from a prevention perspective.
I still think for every dollar you spend on prevention, you’re saving $11–$12 on treatment. If you have limited resources, which every community has, you have to plan on spending some of those resources on prevention. You can’t ignore the treatment aspect of it, but the problem is that the pull of these drugs is so strong that people fail treatment multiple times before they either die or get clean. The supply will dwindle if you take away the demand, and you can’t take away the demand without spending a lot of time and effort on prevention. I spend a lot of my time talking to schools. Kids are talking about it, so we as adults and people in positions who can influence need to start talking. Talking to them early is important, and explaining the real danger is important.

Have you seen that make an impact?
The National Institute on Drug Abuse put out some stats in 2016 that were encouraging. It said 70 percent of high school seniors do not intend to use opioids. I’m still worried about the 30 percent. But the same group also said 70 percent didn’t see anything wrong with smoking pot. I call marijuana a gateway drug. The fact that such a large percentage of our opioid OD victims also have THC in their blood—come on, they’re doing it together, or doing one and doing the other. What we see most, if you talk to people, is that they’re smoking pot and then trying something more dangerous. There was a time when there were a lot of addicts being created from the pain pill/pill mill problem, but now it feels like it’s from risky behavior. I talked to a 23-year-old girl the other day. She’s out of rehab for the third time, but she’s very vulnerable and she’ll tell you that. The pull of it is such a physical tug on her that she asked her mom to take her car keys. I asked why she started—she’s kind of young for what we normally see. She was in college, she was an honor student, and she said that she’d been drinking since she was a teenager and had been smoking pot, and she was at a party where someone had heroin, but it was actually fentanyl. That’s what scares me now. I think we’ve been good at getting the pills under control and tackling it, but I feel like we haven’t been effective at the risky behavior.

Rendering of the forthcoming crime lab in Blue Ash.

Photograph courtesy Hamilton County Coroner

On June 13, 2017, 22-year-old Wyoming High School graduate Otto Warmbier returned to Cincinnati after more than a year in North Korean custody. He died six days later, at which point the coroner’s office took jurisdiction of his body. After months of silence, Warmbier’s parents were interviewed on Fox News in September and accused North Korea of torturing their son, citing scars of unknown origin and considerable damage to his teeth. Their comments sparked a tweet from President Trump echoing claims of torture against Warmbier. In a press conference the following day, Sammarco, referencing the coroner report and disputing the parents’ claims, stated that Warmbier’s teeth were “natural and in good repair” at the time of death, which was attributed to brain damage from lack of oxygen “due to an unknown insult more than a year prior to death.” “We don’t have enough information about what happened to Otto at that initial insult to draw any concrete conclusions,” Sammarco said at the time.

When did the Warmbier case get on your radar? When he was in North Korea, was this something you thought you might play a role in?
No. I knew about it obviously because of the news. I had actually met the Warmbiers a year before at a social thing—they probably don’t remember meeting me. But it didn’t click at the time. I got the phone call from University Hospital when Otto died—the Decedent Affairs office reports to us anything that might be a coroner case, and we evaluate whether we take jurisdiction, which means we accept for the body to come here.

Did you know what you were getting into when you accepted jurisdiction?
I was aware that there could be national and international implications. I actually got a few calls from Washington that day, after we accepted, from elected officials. I understood this could have international implications, and I understood by law the federal government couldn’t take this case from the local coroners, but I offered it. To do Otto justice, I said we would relinquish jurisdiction. The State Department said no.

We had already decided we weren’t going to do a full autopsy, not only because of the family’s objection [for religious reasons] but because of the other circumstances. [An MRI done in North Korea showed that the initial insult to Warmbier’s brain had likely occurred roughly 15 months prior to his death, meaning toxicology was unlikely to shed any light.] So we did an external examination, and I had already asked University Hospital for a virtual autopsy (a post-mortem CT scan). They did that and sent him over, and we did our external examination. We collected body fluids, and then I did talk to his family the next day to try to get some answers about things we noticed during our external examination. And that was about it. When we finished our report and made it final, we didn’t advertise it, we didn’t put out a press release. The funny thing is, prior to the parents going on Fox & Friends, we’d been finished with the report for about three weeks. As far as I know, they hadn’t asked for a copy of it. There was one media outlet that did, and it was The Wall Street Journal, and they got a copy of it, quietly, and nothing was made of it.

They didn’t report on it?
Nope, and I didn’t get any phone calls until the family went on Fox & Friends and CNN.

And after that you held the press conference?
Yeah. I cannot even tell you the deluge of phone calls. There were lots of different questions asked, but the one I felt I could address was the teeth.

The parents talked about the teeth, and you came out and said your analysis didn’t back up their account. What was that like for you?
It was like walking a tightrope. They’re grieving parents, and I can’t even imagine the amount of pain they’ve gone through and all those months that their son was missing, not knowing what was happening to him in a prison in North Korea. I have two children. You can’t make all their decisions for them, and they will make bad decisions in their lives. You hope you’re around them to pick up the pieces, but you can’t. I didn’t want to come out and say anything against them, but it was escalating. We had the President of the United States tweeting based on their comments, and tensions were building between us and North Korea. I felt like I don’t have any control over any of that, but I do have control over addressing this particular subject. And I don’t want my silence to result in nuclear war between two countries, because I didn’t stand up and say something.

Was that the most unusual case you’ve dealt with?
Oh my gosh, it was certainly the one that got the most international attention. Definitely not the strangest. We have had some unbelievable cases.

For someone who was a practicing neuroradiologist and—I’m assuming—took a pay cut for this job, how often do you find yourself questioning why you’re doing this?
There have been lots of times. I can’t tell you how many people have asked me, especially my radiology friends, What possessed you to do this? I don’t know. There are days when even I think, Why am I doing this? There are days where I just feel, when cases have made me lose sleep or given me disturbing dreams, that I think I’m done. But then there are other cases where we can give answers and the families are so grateful, and I feel like we’re doing some good, we’re getting the bad guys off the street. Our little motto here is that we’re so much more than life and death, but it’s also that science and justice reign in the Queen City. That’s what it’s about: Using science for justice. 

Rendering of the forthcoming crime lab in Blue Ash.

Photograph courtesy Hamilton County Coroner

Rendering of the forthcoming crime lab in Blue Ash.

Photograph courtesy Hamilton County Coroner

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