Forensic pathologist Dr. Roger Mitchell joins Raise the Line host Michael Carrese to discuss his efforts to improve tracking of deaths in the criminal justice system, why communities exposed to violence may be suffering from post-traumatic stress disorder, the risk to safety net hospitals from recent Medicaid cuts, and the history and mission of the National Medical Association, the largest and oldest organization representing the interests of Black physicians and their patients.
"We know in public health that if you're not counting, there's no way to develop prevention programs or policies.” That understanding explains why forensic pathologist Dr. Roger Mitchell is working to change how the United States tracks people who die while in the custody of police, jails and prisons. "There is no single federal database that identifies who is dying and how they are dying at the hands of the criminal justice system," says Dr. Mitchell, co-author of the book Death in Custody: How America Ignores the Truth and What We Can Do About It, published by Johns Hopkins University Press.
In this Raise the Line conversation with host Michael Carrese, Dr. Mitchell draws on what he’s learned in his varied career path – which includes being one of the first Black scientists in the FBI's laboratories, chief medical examiner of Washington, D.C., president of Howard University Hospital and president of the National Medical Association – to offer solutions to this data gap and also weigh in on:
· Why communities exposed to violence may be suffering from post-traumatic stress disorder;
· The risk to safety net hospitals from recent Medicaid cuts;
· The history and mission of the National Medical Association, the largest and oldest organization representing the interests of Black physicians and their patients.
Mentioned in this episode:
National Medical Association
Death In Custody book
Michael Carrese
Hi, I'm Michael Carrese, welcoming you to Raise the Line from Elsevier, an ongoing exploration about how to improve health and healthcare.
Today, I'm happy to welcome Dr. Roger Mitchell, immediate past of the National Medical Association, the largest and oldest organization representing the interests of Black physicians and their patients in the United States.
Dr. Mitchell is not new to leadership roles, having previously served as president of Howard University Hospital, Chief Medical Examiner of Washington, D.C., and Deputy Mayor for Public Safety and Justice in that city as well. He's also a board-certified forensic pathologist with over twenty years of experience, a tenured Professor of Pathology at Howard University, and co-author of the book Death in Custody: How America Ignores the Truth and What We Can Do About It, published by Johns Hopkins University Press.
I'm looking forward to discussing his work at NMA, violence as a public health issue, the tracking of deaths in the criminal justice system and the impact of federal cuts to healthcare, among other topics.
Thank you so much for joining us today, Dr. Mitchell.
Roger Mitchell
It's my pleasure. It's great to be here.
Michael Carrese
So, we always start by asking our guests about what first got them interested in medicine, and a lot of the answers can be kind of meandering -- you know, it led this way and the other way -- but in your case, you grew up with a strong role model right in your family who influenced your path. Tell us about that.
Roger Mitchell
Yeah, my grandfather was one of the first Black physicians in Atlantic City. He went to Howard Medical School and graduated there in 1932. He started Lincoln undergrad and then Howard med and then went on and did an intern year and then was a “black bag” doc in Atlantic City.
He died when I was about ten years old. He was in his late eighties when he died. So, I grew up hearing these stories and walking on the boardwalk and people stopping my mother and I and telling me how great my grandfather was because of how he took care of families in their kitchens, in their living rooms, and sometimes didn't even take payment for service. So, I kind of grew up with that and it was my entrance into wanting to be pre-med, but, you know, particularly forensic pathology has a different story.
Michael Carrese
Yeah, so what is that story? What drew you to that?
Roger Mitchell
Yeah, so I was one of the first Black men in FBI laboratories back in 1997. I was a forensic biologist, and while I was there, got exposed to forensic medicine. As a scientist at the Bureau, we did a tour of the local Washington D.C. medical examiner's office, and I was intrigued by the fact that there was a physician scientist performing autopsies and asked whether or not he was an MD or PhD, and he said he was an MD. I had gone to undergrad wanting to be a medical student but had done some research and some DNA work, and that kind of made me want to go into forensics because DNA forensics was just coming out in like the early to mid 1990s.
So, I had this exposure to the medical examiner while at the FBI, coupled with exposure to critical incident stress management. Let me tell you about that. I was an employee assistance program coordinator for the FBI. When an agent would discharge their weapon, my job was to kind of be a point of contact for that agent and then hand that agent off to psychologist or other resources that the FBI had.
During my training for that, I got exposed to critical incident stress management, or post-traumatic stress disorder, and one of the symptoms of being exposed to violence or engaged in violence was violence itself. And I found a connection between exposure and violence and being a perpetrator of violence in communities that I came from. So I made the connection that communities that were exposed to violence may be suffering from post-traumatic stress disorder.
Now, that is a common concept, but in the mid-1990s it wasn't. It was not something that people were making a connection to. So I actually wanted to leave the FBI to study violence as a public health issue, and I felt the best way to do that was to do that as a forensic pathologist.
Michael Carrese
And explain why that is. What's the overlap there?
Roger Mitchell
Well, forensic pathology does the autopsies on sudden, unexpected, and violent deaths. So in any jurisdiction, that forensic pathologist is doing the autopsies on homicides and suicides. I was a medical examiner in New York, I was a medical examiner in Houston, Harris County, Texas, and in New Jersey, and D.C. And in all of those jurisdictions, I or my colleagues saw every single homicide and suicide, so we would see and know the circumstances. You know, what are the social circumstances? What are the actual circumstances surrounding the death?
Now, I'm absolutely more advanced in my understanding of those connections, but as a twenty-two-, twenty-three-year-old, I thought those connections would exist, and they do because of the fact that all violent death cases would come to the medical examiner or coroner's office.
Michael Carrese
So talk about your research into this area. Can give us an overview of your conclusions, and I guess the other sort of natural question is what would you recommend municipalities and other communities do about this, and how are they falling short?
Roger Mitchell
Yeah. So while I was in medical school, I was studying violence as a public health issue, really trying to understand what were the social determinants of violence, right? You know, education, economics, housing, health care, environmental justice. As we know now, they play a big part in disease, they play a big part in injury, and whether or not those are injuries are accidental injuries or violent injuries, the social determinants play a role: where you live, love, work, play, have your being, access to foods, access to care -- all of those things play a part in patient outcomes, whether it's natural disease or injury. Violence is no different, quite frankly, and we know that to be true.
The other side of the work that I do is on death in custody and so exposure to violent deaths in custody got me involved in doing the work surrounding death in custody. But then as I've learned more about death in custody, I learned more about the natural deaths in custody, or the drug overdoses, or the suicides that occur in custody.
All of my career is kind of looked at through a mortality surveillance lens, an epidemiology lens. So taking these epidemiological points in the form of individual deaths, understanding their similarities, understanding their differences, being able to plot them on a map in geography, in a particular jurisdiction like a D.C. -- which is really where the majority of my mortality surveillance work had occurred in my career -- that those geographical point plots give you an idea of the social determinants that influence the community in which that individual lived.
So, as part of the research and work, we overlay access to education. What's the highest level of education? Access to jobs. What's the highest level of jobs? Access to food and food swamps or deserts...what's the access points there? Through this work, we were able to make correlations between the incidence and prevalence of violence -- or the incidence and prevalence of propensity to find someone so incarcerated -- and what can be used to prevent that.
So that's mortality surveillance, but it's also mortality review and developing structures where there's large mortality review infrastructure.
Michael Carrese
And this would be consistent? In other words, if there are certain factors and determinants in place in any community, you're going to see violence. Is that a shorthand way of understanding this?
Roger Mitchell
Yes. There is a complexity that goes along with the environment. So not everyone who lives in a poor community or in a community that doesn't have as much education is going to be violent or a victim of violence. But there's risk factors that are associated with that violence. And whether it's an urban center or rural environment, it really doesn't matter. There's a propensity towards not only violent behavior, but violence being placed upon community in the form of over-policing.
Michael Carrese
You mentioned the book Death in Custody and, you know, it's a very sobering idea that there are a lot of people in government custody that are dying and we don't talk about it and nobody seems to know all the factors involved. So tell us about what are the key drivers of that?
Roger Mitchell
Well, we wrote the book largely because when I was attempting to identify data surrounding those that are dying in custody, I found that the data is incomplete. There is no single federal database that identifies who and how individuals are dying at the hands of the criminal justice system -- whether it's in the pre-arrest phase like a George Floyd or it's a fully incarcerated phase like a LaShawn Thompson.
We don't have a full number and count and we know in public health that if you're not counting, then you can't prevent. In the hub and spoke model, if you're not doing research at the hub, then there's no way for you to develop programs of policy and quality control or measures to decrease morbidity and mortality.
Because of that we set out to understand where in history have there been inconsistencies surrounding death in custody, who has been at the center of these inconsistencies and where there's opportunity. Where in history have individuals been successful in pulling together data sets? We found that advocates and journalists have been the primary place where the majority of the data's come from, although in the early days of the Deaths in Custody Reporting Act -- which is the federal law that requires every single state to report death in custody -- there was a strong push and some really good data in those early years from 2000 to 2013, and then 2013 to 2017 but it was inconsistent. Not all deaths have been recorded across every state.
So the book calls it out, and calls for a more robust way and system through stories, historical stories, and context, but we ultimately say that it's a public health issue. And if it's a public health issue, then we believe the Centers for Disease Control’s National Vital Statistics System should be the ones capturing data on death in custody and right now the law falls short. It only calls for the Department of Justice to capture death in custody.
Well, there's no other deaths in the public health sphere where the criminal justice system is responsible for categorizing those deaths. But when it comes to death in custody, why isn’t arguably one of the most robust vital statistics systems in the world at the CDC capturing it? So, we've devised and are advocating currently for a “death in custody” checkbox on the U.S. standard death certification.
Michael Carrese
And is there receptivity to that, or are you finding resistance?
Roger Mitchell
Well, I've been at this now for over a decade, Michael. Initially was, well, you know, that costs money. When I first started trying to get the checkbox on the U.S. standard death certificate, it was a paper death certificate. So that's how long I've been at it. Now we're using an electronic death certificate. So, it's no longer really cost prohibitive, and there's no longer an excuse that there's no room on the death certificate, because now it's electronic.
But then it was, ‘well, at the federal level, we don't like to mandate reporting practices, so we really like for the states to come to a consensus on what goes on the new version of a death certificate.’ The death certificate usually gets reevaluated every ten years. It's been over twenty years since this death certificate has been revised, and so we're asking for that.
We've gone state by state. The Washington, D.C. government has a checkbox on the local death certificate. There is a current legislation in Delaware to put the checkbox on the Delaware death certificate. We think that that's going to happen. There has been legislation in Pennsylvania for a checkbox, although that has stalled, and we don't believe that that is going to happen. We'll see. We're hoping that we can have conversations state by state to the point in which the federal government feels it's important.
And quite frankly, there was a report that just came out about this. I was part of the research committee for the National Academies of Science, Engineering, and Medicine called Strengthening the Medical Legal Death Investigation System: Lessons from Death in Custody. In that report, the authors call for a checkbox on the U.S. standard death certificate. So the National Academies -- arguably one of the premier institutions to help set health and science and engineering policy in this country -- has suggested that we need a checkbox.
Michael Carrese
I hope eventually they agree with that. Seems to the outside observer that getting a checkbox on a form wouldn't be such a struggle, but I know everything's very complicated when you're dealing with the government.
Speaking of the government and big social knotty problems, I want to ask you about Medicaid cuts and how they're playing out. I mentioned in the intro that you were the president of Howard University Hospital -- one of the really prominent safety-net hospitals in the country. At the time of the "big beautiful bill" cuts going through, there was a lot of concern what this would mean for safety-net hospitals and rural hospitals as well. As someone who has run one of those, I'm just curious what your take is on how these cuts are playing out and the impact they're having on patient care.
Roger Mitchell
Yeah, the cuts are forcing people into the emergency departments, and it's only gonna get worse. Individuals that really, in the days of inflation and the high costs in this country, were considered poverty level and would have qualified for Medicaid, now don't. Their financial situation hasn't changed much to allow and afford them, particularly families beyond an individual, but true families.
We're talking anywhere from $1,000 to $2,000 every single month for families. That's more than their rent, and if they own, it would be more than their mortgages, to be able to provide health care that allows for prevention, allows for lower copays. So, you know, what we'll see is what we've seen in the past: more people accessing clinics, and accessing them and not being reimbursed, and those clinics having higher burden, and then those people that are accessing health care through the emergency department with a higher severity of their disease or complications of their injury, and that ultimately it increases costs for an organization like a safety-net hospital, whether it's rural or urban, especially those that are seeing majority Medicaid patients.
At Howard Hospital, when I was president, upwards of 85% of our population were Medicaid and we know Medicaid reimburses 30 cents on the dollar. And so it's gonna put a stretch on these hospitals, and we'll see more hospitals closing before it stabilizes, I'm sure.
Michael Carrese
Yeah, and you are seeing it, I know, in rural areas, because I happen to come from a rural state. It's happening already, so it's really very concerning. We could spend the rest of our time talking just about that, but I do want to get to your work at the National Medical Association. You were president there for a one year term. Can you help us understand more about the NMA and its mission?
Roger Mitchell
Yeah, so the National Medical Association was started in 1895. At that time, the American Medical Association would not allow admission of Black physicians into the AMA, but you needed an association affiliation in order to get hospital privileges. This is before the days of medical staff offices that credentialed physicians. It was the associations that would vouch for credentials. And so in 1895, we started an organization that would allow for us to have that community to be able to justify our credentials in hospitals, particularly hospitals that were being built and run for and by Black folk in this country.
So, the mission has been making sure that there's equity and access and parity on care for patients in communities that need it -- no matter what their color, creed, or religion -- and making sure that physicians had opportunities to serve those patients. We still hold that to be true even now. I was the 126th president, and we worked on things like AI and innovation and ensuring that the regulatory framework for AI takes in mind the diversity of patient population and need within community; environmental justice, including understanding the effects of plastics, microplastics, fossil fuel, clean water, clean air, something that's important beyond any community.
We've taken on vaccines as a staple of what innovative medicine and science has been in this country, and holding onto the importance of vaccinations and pushing back on notions that vaccinations somehow can be beyond detrimental if properly done; and environmental justice issues like death in custody and violence and limb salvage amongst African American men and women. We find that limb amputation in general is higher within African American communities, and we know that there's a higher mortality rate surrounding below-the-knee or above-the-knee amputations. And so we've taken that on as a justice issue.
We also deal with workforce issues. You know, there's a whole push and suggestion that if you somehow are culturally different, specifically Black people, if you're Black and you're in medical school, you somehow got to medical school, and you're less qualified to be a physician, and programs that look to retain and recruit for diversity in medical schools somehow are doing harm in medicine versus not.
We have pushed back on that notion and ensuring that we have a robust workforce plan and pathway for students that not only come from our community, but students that want to serve our community, which can be different than the community that they come from. Because the most disenfranchised and disinherited communities need physicians that wanna serve in those communities, no matter what their background is, and that diversity, often the diversity of culture and race, act as a surrogate to those individuals that wanna go serve those communities.
And so, so the NMA is, is strong, and we have over 3,500 active members. We represent 50,000 Black physicians in the country.
Michael Carrese
And is the cohort of Black physicians growing? I mean, it's obviously underrepresented in terms of its level in the population at large, but are you seeing growth?
Roger Mitchell
No, unfortunately. I'll tell you, depending on what statistics you look at, African American physicians make up about 5% to 6% of all physicians. We saw an 11% increase, I think, in 2024 to 2025 of medical school applications from African American students seeking to be medical students, but we saw a decrease in their admissions as of late. There's not a lot of analysis being done on that. And in fact, today you can't find accurate data because several of the organizations that have been keeping the racial demographic data are no longer keeping that data.
The Liaison Committee on Medical Education (LCME) does not require diversity as part of recruitment and retention for medical schools, and it used to be a requirement for accreditation. You had to show how you were doing that. Now it's no longer a requirement. So many of those schools don't even keep the data as a nod to the requirement, and quite frankly, what often people believe is there’s retribution. I mean, there are lawsuits against medical schools now coming down because of their want and need to think diversity is important to the field of medicine.
Michael Carrese
It's a very, very tough environment, obviously, for DEI. I'm afraid to say we're close to running out of time. We always like to ask our guests as a final question what general advice they have for the medical learners and young clinicians in our audience about meeting the many, many challenges of the moment and building a career in medicine...
Roger Mitchell
Wow, in the last couple minutes. There's so much advice. I teach medical students and residents. I think, you know, one of the first things that I say to my medical students is to become passionate about that one thing, right? Whether it's that research question or whether it's that social issue -- whatever that thing is, become passionate about it. Become the expert in it. Learn about it, do the research, publish in it, teach it, you know, become immersed in it, and then use your voice as you would see fit and use your white coat for the individual patient at the bedside or the patients in your communities.
My work in violence prevention and death in custody started as a second-year medical student. I started working in publishing and doing research and writing programs and writing policy as a second-year medical student, which acted as the foundation for the work that I do now. I’ve been a chief medical examiner in multiple major cities. I was a deputy mayor for public safety and justice. I was a president of a hospital and of a major association.
All of that started with a willingness to trust that I might have an idea or an interest that uniquely can move medicine and the health of our community forward. I believe that each young learner and medical student has that unique thing in them, and so don't be afraid to pursue it.
Michael Carrese
That's great advice, because we do hear about medical students doing the thing they think is gonna give the most secure future financially, or get them the most recognition and so forth, and are afraid to follow the passion. So it's nice, I think, to have that reinforcement that really the passion is what yields the meaningful career that you've had.
Roger Mitchell
Yeah, and the money comes, you know. The money comes. But imagine, there's thousands of families that I've had the opportunity to meet and to support in their hardest time, and they continue to thank me. Similar to my grandfather, I walk down the street and there's families that thank me for what I've done for their family member. And that's really why we get into medicine, at least why I did, is to make a difference—the cliché. And so if you want to make a difference, follow your passion.
Michael Carrese
Well, that's a beautiful full-circle note to end on there with our interview today. Dr. Mitchell, thank you so much for your time, and I wish you all the best of luck in your work.
Roger Mitchell
Thank you, Michael. Thank you for taking the time.
Michael Carrese
I'm Michael Carrese. Thanks for checking out our show, and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.