Thanks to the 2.7 million death certificates that stream electronically into his office at the Centers for Disease Control and Prevention each year, Bob Anderson can see how the most deadly drugs are ravaging America.
He knows that fatal overdoses involving cocaine doubled in 2016. He knows that in more and more of those cases fentanyl was part of the fatal cocktail. And he knows deaths from illicit synthetic drugs are spiking.
But Anderson can't tell if these trends are happening across Pennsylvania.
Because when he looks at death certificates from the state, nearly half of those for fatal overdoses have a gaping omission — the drugs involved. Only Louisiana has a worse record. Among the Pennsylvania counties with available data, Philadelphia ranks last. It specified which drugs led to overdose deaths on just 7 percent of 746 death certificates in 2016, according to the most recent CDC data.
"So many of the drugs aren't specified," Anderson, chief of the CDC's mortality statistics branch, said of PA's numbers. "… We have no confidence they reflect reality."
The CDC's mortality data, collected from death certificates submitted by every state, play a critical role in the world of public health. In relation to the opioid crisis, public health workers, researchers, elected officials, journalists, and average citizens use the information in countless ways, such as to track trends over time, compare states, and find emerging threats.
For example, after Kentucky made a push to collect toxicology information on overdose death certificates, officials discovered that a particular prescription muscle relaxer was involved in nearly a third of all overdose deaths. Armed with that information, the state legislature deemed it a Schedule V drug, allowing the state to track prescriptions for it.
The commonwealth lacks critical data at a time when the opioid epidemic shows no sign of slowing. County coroners and medical examiners in Pennsylvania typically maintain such data for fatal overdoses, yet much of the information isn't shared with the state and federal government via death certificates.
Philadelphia's medical examiner, physician Sam Gulino, has defended his approach, which he said is designed to handle death investigations as quickly as possible, largely to give closure to families. The office handled about 1,200 drug overdose cases last year, nearly three times the 2013 toll.
His current system allows Gulino and his office to declare drug intoxication as the cause of death for about 75 percent of the suspected drug cases it receives within about 24 hours. They do so using circumstantial evidence from the scene and a rapid toxicology test that can identify some drugs but not all, and not with enough specificity for a death certificate.
His office still completes full toxicology testing on those cases but said it can take up to 90 days. Waiting for that information before declaring a cause of death would require his office to mark all of those cases — approximately 900 in 2017 — "pending." He said doing so would cause a backlog while leaving grieving families in the dark or waiting for documentation needed for insurance claims.
"Some people express they have a really hard time moving forward with their grieving process if they have this question mark hanging over what the cause of death might be," Gulino said.
His office could also go back and amend the death certificate once toxicology information is available. But he said that would burden his already taxed staff. (Anderson, from the CDC, said it is common for many states to amend death certificates.)
Gulino said he would be happy to give the CDC the information directly, but Anderson said his office is only equipped to take mortality data through state death-certificate data.
On the other side of the state, Allegheny County Medical Examiner Karl E. Williams, a physician, has a very different approach. He called it "shameful" that Pennsylvania has nearly the worst record in the country of reporting the information on death certificates.
His county, which includes Pittsburgh, provided drug information on 98 percent of overdose death certificates in 2016, according to the CDC.
That is possible because he issues a "pending" cause of death for nearly every suspected drug case his office handles. When full toxicology is complete he issues a final death certificate, including the contributing drugs.
Williams said in most cases family members know the deceased had a history of drug use or could guess drugs were a factor given evidence found at the scene. He said his own process is driven by a belief that law enforcement, the public, and officials at all level of government can only address the epidemic with data in "as granular a fashion as possible."
"If we want to know how to attack the problem it's going to be driven by data," Williams said. "… My overdoses in Allegheny County are very similar to Westmoreland County, right next to us. They are very different than Lackawanna County or Erie County. It happens at a local level. Overdose happens at a neighborhood level."
Pennsylvania's reporting failure comes at a time when overdose deaths are spiking. Gov. Wolf last month declared the opioid epidemic a statewide disaster. The state saw a 28 percent increase in overdose deaths between 2015 and 2016, resulting in the fourth-highest death rate in the country, according to the CDC. Nationally drug overdose deaths were up 21 percent in that period.
Wolf's declaration keyed in on better reporting from first responders about those who overdose and are revived, not more complete death certificates. April Hutcheson, spokeswoman for the Pennsylvania Department of Health, said the department wants more robust data from coroners and medical examiners, and the disaster declaration could open up those discussions.
"The overdose rate is what tells you what the severity of the problem is," she said. "That severity is where we need to target our resources. The overdose deaths are compelling. But we need to get the people who are suffering from overdoses into treatment so they don't become a death."
Hutcheson said officials supplement death certificate information with reports done by outside groups, including an annual report by the Philadelphia division of the U.S. Drug Enforcement Administration. But she said officials only have access to the report, not its underlying data.
Patrick Trainor, a public information officer for the Philadelphia DEA, said the office compiles its report using data provided by coroners and medical examiners without the name of the deceased. Trainor said some offices provide the information willingly, while others have to be subpoenaed.
Pennsylvania, while not alone in underreporting toxicology information on death certificates, has been at the bottom of the pack for decades. Other states have improved over time, and in 2016 about 85 percent of the nation's death certificates for overdoses included contributing drug information.
The structure of Pennsylvania's health system — with a state medical examiner who receives death certificates from county coroners and medical examiners — makes finding a solution more complex. A mandate requiring county offices to provide toxicology information on death certificates would have to come through legislation, not from Gov. Wolf, Hutcheson said.
States with coroner systems often have an added challenge, given that coroners are elected and not required to be physicians. Many are funeral directors.
Still, other states with county coroners and medical examiners have made progress.
In South Carolina, for example, Gov. Nikki Haley in 2014 sent letters to county coroners asking them to add drug information for all overdose deaths from the previous year. State staff also attended a meeting of the state coroners association and explained the need for the information. From 2013 to 2014, reporting increased from 58 percent to 94 percent.
Pennsylvania has recently been identified as one of three states that a national public health association and the CDC want to help improve their cause-of-death reporting systems. Christi Mackie, a chief program officer for the Association of State and Territorial Health Officials, said Pennsylvania's Department of Health agreed this month to participate.
"Our intent is to step in and say, Where do you see gaps? Do you need us to help you identify what those gaps are?" Mackie said. "And then we can see what kind of bandwidth we can add to support their capacity."
In Pennsylvania, though, some coroners and medical examiners are resistant to the idea.
Kenneth A. Bacha, a funeral director who has been coroner in Westmoreland County near Pittsburgh for 16 years, said he doesn't list drugs in part to protect the deceased's privacy, should they have been taking medication for depression, HIV, erectile dysfunction, or other conditions he considers sensitive. Death certificates are not public in Pennsylvania, but Bacha said they can be used by families to close out bank accounts, file for insurance, or transfer a car title.
"It's not public where anyone can go look at it, but other people are going to have access to it," he said.
Some Pennsylvania coroners and medical examiners said it's unlikely someone would overdose from a drug that treats HIV or erectile dysfunction, so they probably wouldn't include those medicines, focusing instead on the drugs responsible. But Bacha said he does not always feel comfortable deciding the exact drugs that contributed to a person's death.
"We had one the other day, the person had heroin in them, three different types of fentanyl, oxycodone, plus a bunch of benzodiazepine-type drugs, psych drugs. … As far as which ones you pick, one over another, I don't know how they could do that."
Delaware County Medical Examiner Frederic Hellman, a physician, said he makes those calls routinely.
"I look at which drugs I think were the likely players in the person's death," he said. "And that's understanding the nature of the drugs, the concentrations of the drugs, the interactions between the drugs."
Alexander Balacki, first deputy coroner in Montgomery County, said he has listed as many as seven or eight contributing drugs on a death certificate. He called the approach fair to both the family and the public.