#WhatItsLike: Top forensic pathologist on his career at the autopsy table
Warning: This article contains references to suicide and graphic descriptions of dead bodies that some readers may find upsetting.
It’s day one of the Forensic DNA Symposium, recently held in Cape Town as Professor Ryan Blumenthal relates anecdotes on his life as a senior specialist forensic pathologist at the University of Pretoria.
“Let me tell you, working in a mortuary gives you a good idea of what’s going on in the world. Just from my autopsy table, I can tell if a new gang has moved into the neighbourhood, if there’s a new or emergent drug in town or a new disease. We get insight into the state of the nation from there,” says Blumenthal.
You’d be able to hear a pin drop in the packed conference room, as Blumenthal – also the author of the book, Autopsy: Life in the trenches with a forensic pathologist in Africa – is giving an account of what it’s like working at the frontlines of death in South Africa, sprinkled with some sobering statistics and realities facing the country.
Spotlight interviewed him after.
Part scientist, part doctor, and part philosopher, the bespectacled Blumenthal (49) is crystal clear about why he does what he does. “The battle is personal… I just want to catch the bad guys,” he says, while also lamenting the dire shortage in South Africa’s forensic pathology workforce. His main push, he says, is to stress the need to take DNA samples from victims in homicide cases “because it can help catch criminals”.
This is what it feels like. You wake up. You go into the cold, hard world of the mortuary, into the mud, blood, and guts of it all and you have to find out what happened,” he says. “You know that, at the end of this, there are families. It’s about the pursuit of truth, the administration of justice, and closure.
During the height of the COVID-19 pandemic, as an essential worker, he says he saw five trends – an increase in suicides (“hanging was the way to go; the youngest I saw was seven”); increased addict-related deaths (“people weren’t getting their fixes, and were making their own”); increased interpersonal violence (“there was nowhere to hide”); and, coming out of lockdown, high road traffic fatalities.
“But the most indicting of all, when the lockdown ended, we saw a lot of skeletons and decomposed bodies because nobody was finding all the lonely people,” he says.
The duties of a forensic pathologist include determining the cause and manner of death, identifying the deceased, collecting evidence from the body, documenting injuries and underlying natural diseases, attending death scenes, and providing expert testimony.
“This is what it feels like. You wake up. You go into the cold, hard world of the mortuary, into the mud, blood, and guts of it all and you have to find out what happened,” he says. “You know that, at the end of this, there are families. It’s about the pursuit of truth, the administration of justice, and closure.”
You also learn about people’s folkways, their cultures, and sub-cultures at the autopsy table.
Blumenthal uses a quote by Britain’s top forensic pathologist, Dr Richard Shepherd, to describe his work. “A lifetime of bearing first-hand witness to, on behalf of everyone – courts, relatives, public, society – man’s inhumanity to man.”
He says he often speaks to grieving families of the deceased. “Often they want to understand what happened. Remember, we’re here to serve, to soothe, and to solve. We’re still doctors. We took the Hippocratic oath. However, you always want an investigating officer present, because sometimes the family might be the perpetrators.”
At the autopsy table
Blumenthal is one of many forensics experts from around the world at the symposium held on 13 and 14 June. The symposium is the third of its kind in SA and the largest in Africa. A key focus is the use of forensic DNA evidence in gender-based violence cases to help identify offenders.
“You also learn about people’s folkways, their cultures, and sub-cultures at the autopsy table,” he says. “As somebody is lying there, I can tell you they’ve made bad choices in their life because all your choices leave signs on your body. The body speaketh with miraculous tongue.”
In his work and personal life, Blumenthal – an avid supporter of Locard’s Exchange Principle, says he usually sees patterns in everything. The principle is named after the French criminologist Dr Edmond Locard (1877-1966), who became known as the Sherlock Holmes of France. The principle holds that, in forensic science, “every contact leaves a trace”. Blumenthal says people are the sum result of every contact they’ve ever had in their lives. “So, you have to watch what you eat, what you expose yourself to… and be mindful of your contacts as you grow older. By doing so, not only will you be happier, healthier, and grow old better but we forensic pathologists will have less work,” he says.
“For example, I can see that the anterior abdominal fat wall thickness of South Africans is getting bigger. Normally it should be one to two centimetres. I’m getting a lot of people who are three to four centimetres. This tells me there is some chronic carbohydrate poisoning going on – we’re slightly overweight here.”
He gives another example. “About a year ago, we had a case in Pretoria where people died in a house and that was the first case I’ve seen of gamma-Hydroxybutyric or GHB. We hadn’t seen this in Pretoria before, but it’s common overseas.” GHB is often used recreationally in what is known as chemsex and it also has street names like liquid ecstasy and Great Hormones at Bedtime. “It has now entered our culture.”
At the autopsy table, Blumenthal says forensic pathologists also have unique insights into gang activity.
“Certain gangs have certain initiation ceremonies, so if we come across a way of killing people that is idiosyncratic to that particular gang, we can make deductions. In my jurisdiction, we’ve been seeing a lot of multiple shooting cases. We call them multiple multiples. In one case, the body had 70 gunshot wounds on it. It’s not rocket science to deduce that something is going on in our society. These are angry crimes.”
Blumenthal has performed thousands of autopsies, many of which have helped track down the perpetrators of crime. He did 32 of the Life Esidimeni autopsies and seven of the Marikana ones. He has dealt with high-profile deaths, including a president (although he won’t say which one), mass disasters, and deaths caused by African wildlife. He says he has read hundreds of suicide notes. Then there are the deaths unique to South Africa, like those caused by necklacing and those related to the use of traditional medicine.
The South African reality
Painting a picture of the South African reality, Blumenthal says every year there are about 70 000 unnatural deaths in South Africa. They include around 25 000 homicides (about 70 a day), 15 000 road traffic deaths, and 10 000 suicides. These unnatural cases – as opposed to the country’s approximately 500 000 natural deaths from cancer, TB, HIV, etc. – require medico-legal autopsies, which are performed by forensic pathologists. South Africa, he says, is suffering a serious shortage of forensic pathologists.
The Western Cape has 40 forensic pathologists; Gauteng has 18; Free State 16; KwaZulu-Natal 11; Eastern Cape ten; and North West seven. Some provinces have none. In rural areas and places without qualified forensic pathologists, autopsies are done in compromised settings, he says.
Every year there are about 70 000 unnatural deaths in South Africa. They include around 25 000 homicides (about 70 a day), 15 000 road traffic deaths, and 10 000 suicides.
“Just to play the game, we need 155 forensic pathologists in South Africa – but 300 would be paradise. Currently, there are about 80 of us nationwide. In Pretoria, where I work, and which has 11 doctors who perform autopsies, we had 2 237 unnatural deaths last year. In America,” Blumenthal says, “a forensic pathologist is not allowed to perform more than 250 autopsies per person a year. In SA, we are performing 450 to 650 per person per year, which includes many multiple cases, like multiple shootings. There are many dedicated forensic pathologists here working very hard in sub-optimal conditions to try and get justice.”
He says many of his students have emigrated. “We are all overworked at the moment, doing an average of three to four autopsies per pathologist per day. It takes its toll and there’s not enough time to do our research. Service delivery overrides everything. The constant exposure to death and the dark side of humanity takes its toll.”
On top of this, he says, there are many small towns that have no forensic pathologists.
“There are gourmet autopsies and peek-a-boo autopsies out there – and a lot of our time is spent redoing autopsies performed from the periphery. Sometimes the body has been buried and we have to do an exhumation. These challenges are labour intensive so there are a lot of issues that need to be addressed.”
The context is also changing rapidly. The main forensic textbooks in South Africa, he says, were written about 25 years ago when there were fewer people in South Africa. In the next 15 years, there is extreme population growth predicted for southern and eastern Africa. “The scary thing is that there are now 61.41 million people in South Africa. In the last 23 years, the population has grown by 16 million and not much has changed in the way of infrastructure.”
‘a life constantly facing death’
In a one-on-one interview on the sidelines of the conference, Blumenthal looks tired, even pale, but his sense of humour remains very much intact.
He was born and raised in Pretoria, he says, to a father who is also “in medicine” and an artist mother. “My grandmother was one of the first female butchers in South Africa and my grandfather was an actuary. I’m the fused genetic material between butcher and actuary, so I’m a thinking man’s butcher.”
we have a very big “offender-driven mentality in this world”. We need to be more victim-oriented.
There’s a poignancy behind the matter-of-fact talk of daily death. During his talk, for example, the slides in his presentation tell a story of a life constantly facing death. He shows a photograph of a mountain – “some days I’m on top of a mountain as people like to hang themselves at the top of a mountain, maybe because of the view”. Then an image of a man in a hard hat entering a cave – “some days I’m in caves because sometimes people like to kill themselves in caves”. A photograph of a smashed, overturned train follows – “some days I attend mass disasters – and the world feels very big…” Then a photo of Blumenthal peering into a high-tech microscope – “most days I’m in my mortuary… and the world feels very small.”
He studied medicine at the University of Pretoria before going on to qualify in forensic medicine. “There are very strict processes to become a forensic pathologist in South Africa,” he stresses. Blumenthal studied for 23 years and has six degrees, including a PhD through the School of Electrical Engineering at Wits.
He believes no other field in medicine offers the intellectual challenge of forensic pathology. “It requires a working knowledge of diagnosis and treatment in almost every specialty of medicine. It also calls for an understanding of non-medical fields like criminology, criminalistics, engineering, highway design, police science, and a deep understanding of a community – its mores, folkways, and religion.”
A nature lover, who enjoys birdwatching and mountain biking, he is intrigued by the phenomenon of lightning and can’t understand why people travel to the northern hemisphere to see the northern lights, “when on the Highveld you can see real drama play out before your eyes… as beautiful as it is deadly…” Among his hobbies, he says, are puzzle solving and sleight-of-hand magic and he is now going through a stage of reading books from the 1930s.
Arguing for mandatory DNA sampling
During his talk, titled The Imperative of Mandatory DNA Sampling in Homicide Cases for Advancing Justice, one of the key take-aways – and something he feels passionately about – is that forensic scientists should take DNA samples from the victims they do autopsies on.
He cites cases that demonstrate the need for this, including the well-known Rachel Nickell case, where a young woman was murdered in the UK and a man was wrongfully accused before the real murderer was caught, years later, using DNA evidence.
“In this case, the DNA material was stored and it helped catch the perpetrator. There are many factors to consider around this like how long do you store the DNA? We live in an increasingly litigious world, so ideally we should store it for perpetuity, especially with new technologies coming in the future,” Blumenthal argues.
I am arguing, insisting actually, that we should take DNA in all homicide cases… because the case is about the victim.
“In terms of the Inquests Act we, as forensic pathologists, are mandated to take whatever tissue we want if we think it will solve the case. Generally speaking, DNA is only taken in open-wound cases like stab wounds and shootings. I strongly propose that we take DNA in all homicides, even in blunt force trauma cases because, as Locard’s Principle tells us, it’s not just about finding traces of the perpetrator on the victim, it’s also about finding traces of the victim on the perpetrator. We need that information. It’s a fatal mistake not to take the sample. We can only find what we test for. If we don’t take the sample we’ll never know.”
According to Blumenthal, we have a very big “offender-driven mentality in this world”. “We need to be more victim-oriented,” he argues.
“I am arguing, insisting actually, that we should take DNA in all homicide cases… because the case is about the victim. I understand there are ethical and human rights problems related to storing innocent victims’ DNA, but the argument is invalid because you have a murder victim here and if murder doesn’t make the news then that to me is news. We have to do everything we can to catch bad people and this means taking all relevant samples. It’s about pursuit of the truth and if you don’t take these samples, bad people will walk free.”
In advocating for this – which would entail taking about 25 500 DNA samples a year, Blumenthal sees himself as a “small cog in a big machine”, aiming to get efficient processes in order.
“My mandate in life is to improve forensic pathology services and the administration of justice,” he says. “I just want to catch bad guys.”
*Blumenthal’s new book, titled ‘Risking life for death’, is out on 12 July.
*The South African Depression and Anxiety Group has a valuable list of helplines on its website for people at risk of suicide.