When someone dies unexpectedly outside of a hospital in Marion County, Alfarena Ballew, chief deputy coroner, gets a call.
She or someone on her team will travel to the deceased’s home to start a death investigation. She takes pictures of the scene, examines the body, looks into the medicine cabinet. And she asks questions of family members: What did this person typically do? Did they work? Were they depressed, or did they use drugs?
She’s looking for clues.
“All of these things are compiled together like pieces of a puzzle,” says Ballew.
There’s no shortage of statistics about death in Marion County, Indiana. For instance, homicide is the leading cause of death for 18 to 24 year olds, according to the 2014 community health assessment. And the county’s suicide rate is 30 percent higher than the national average.
But the individuals who make up these statistics have a common connection: the coroner’s office.
With each death, Ballew learns a lot about how someone lived. In her office, they use all this information, along with an autopsy in some cases, to determine how somebody died.
The majority of the deaths her office investigates are natural. For instance, someone who’s older, who has a history of smoking, or a chronic illness — both common traits in Marion County.
“We say they have the right to die, because it causes stress and deterioration of the body,” she says. “We know life expectancy would not be as long as it would be ordinarily.”
It’s the unnatural deaths — the accidents, homicides and overdoses — that stick with Ballew. She spends more time on those cases, so amid the daily grind, she starts to see trends.
When Ballew started at the coroner’s office in 1997, cocaine and crack were popular in Indianapolis. She saw people die from using the drugs, as well as homicides tied to drug-related activities.
In the early 2000s, crack and cocaine gave way to prescription opioids. More and more, her team started finding pain medications at the scene of a death, sometimes prescribed by multiple doctors or from pain management clinics.
Then, around 2013, Ballew noticed another shift.
“We started to see an explosion, literally, an explosion of heroin deaths. And this as all over the city, and it was all income levels,” she says. “It’s still alarming to me what we are seeing.”
In 2013, Marion County saw 203 drug poisoning deaths, which include heroin overdose deaths. The next year, the county saw 243.
Her team’s clue-hunting changed from looking out for crack pipes or straws for snorting cocaine, to looking in toilets for stashes of pills. And now, for syringes. In the bathroom, underneath rugs, mattresses, cabinets.
“Sometimes we find them in unexpected places, in an attempt for someone to hide their own drug use, or someone else’s,” she says.
“Some families are in denial, or don’t want to talk about it,” she says. “Some families were completely surprised.” Either way, she has to tell them about what she finds.
The information she gathers trickles up.
“It's the responsibility of the coroner's office to see certain trends and to report those trends to other agencies,” she says. Those agencies can then try to fix problems in the community.
Data goes to the county and state health departments, and eventually national centers like the Centers for Disease Control and Prevention. So the widespread attention on the opioid epidemic is, in part, traceable all the way back to information gathered at coroners’ offices.
But it takes time for data to make its way through the system. Two years after Ballew started noticing a heroin surge, the state launched a heroin task force. By now, Ballew is worrying about the next trend she’s seeing, synthetic opioids like fentanyl.
And she wonders what it will take to rally community support to tackle this problem, to provide enough drug treatment resources. It’s not as if the drug problems she saw in the 90’s have been eradicated. “We still have people using crack,” she says. “So what is it going to take for heroin to be removed from the street?”
And beyond drugs, Ballew is able to spot other patterns about how people in Marion County live and die.
“There are more white males that die as a result of suicides,” she says. “We have way more black males that are dying as a result of homicides, and typically we see more male babies die in infancy than females.”
Marion County’s infant mortality rate is one of the highest in Indiana.
Seeing these deaths up close can be difficult. But Ballew was born and raised in Marion County. Her family lives here, and the deaths she investigates are her neighbors.
So she sees part of her job as prevention. She educates people about drugs by speaking to high school and college students about what she sees. And she does her best to explain what happened to families, to help them understand why their loved one died, what the next steps are, how to grieve.
“For me, learning supersedes the emotional side of it,” she says. “What I enjoy most is being able to talk to the families.”