TERRY GROSS, host:
This is FRESH AIR. I'm Terry Gross. Soldiers who have died in Iraq and Afghanistan can still tell stories about how they died through their autopsies. It was the decision of my guest, Captain Craig Mallak, to perform autopsies and CT scans on all of the fallen in Iraq and Afghanistan. Mallak is a Navy pathologist who is the chief of the Armed Forces Medical Examiner System, which is part of the Armed Forces Institute of Pathology. Captain Mallak performed some of the autopsies himself. The results are made available to families of the dead and to researchers who are trying to learn how to better protect American soldiers.
Consider this famous quote from the Annals of Pathology: Let conversation cease. Let laughter flee. This is the place where the dead come to the aid of the living.
Captain Mallak, welcome to FRESH AIR. Since your office has done so many autopsies and CT scans of the fallen in Iraq and Afghanistan, what are some of the fatal injuries that you've seen that have helped you understand where our men and women are most vulnerable and how we can overcome those vulnerabilities, through either better medical equipment, better medical technology, better armor?
Captain CRAIG MALLAK (Pathologist, Armed Forces Medical Examiner System): Well our service members die in a variety of ways as you can imagine in the time of war and some of them are similar to what is seen in the United States with gunshot wounds or drownings. But we also see a number of blast injuries and that has been one of our major focuses is on how to protect our members when they encounter a blast device such as an IED or another munition that is designed to hurt or kill them. And that information and those wounding patterns are provided to those who designed this material - and in an effort to provide better coverage, provide better vehicle design.
GROSS: So can you give us an example of how a vehicle, or how armor or medical technology, has been redesigned as a result of what you've been seeing in autopsies and CT scans of the dead?
Capt. MALLAK: We don't talk too much about it because those changes then would be known to those that are trying to hurt our young men and women out there so - but in the medical field, we did help redesign a way to treat collapsed lung or - it's called a pneumothorax, is the medical term. And we found that the catheters being used by the emergency responders were not long enough to get into the chest cavity to release the air that's trapped there. And over the course of about a month, we looked at a hundred different chest wall thicknesses and we found that our soldiers and Marines have thicker chest walls than those of the average American and the needles were not penetrating the chest cavity. So the Army Surgeon General sent out a memo and changed the methodology to treat these injuries and hopefully save lives.
GROSS: So is this because men in the military are more bulked up, that they work out more so they have bigger chest muscles, and therefore the tubing isn't long enough to get to the collapsed lung?
Capt. MALLAK: It wasn't long enough to get into the chest cavity and that's probably true. Well they're also a younger population in general where you don't want to use a too long needle where you could actually go in and damage something. We found that that wasn't the case, where American military that are young and in very good physical shape, that by using this longer needle, it wasn't placing them at any additional risk, but it was needed to provide the appropriate medical treatment.
GROSS: Now the process of autopsying and providing CT scans for all the fallen in Iraq and Afghanistan, this is like a relatively new policy that I believe was started under your tenure with the Medical Examiner System. Is that right?
Capt. MALLAK: Yes ma'am. In previous conflicts, they did some autopsies in Korea and in Vietnam and very few in the first Gulf War, but at the beginning of this conflict, our office decided as a group that we were going to fully account for each of the fallen, and that included a complete examination and then providing information to the families so they had a better understanding of what happened to their loved one.
GROSS: So how does this work? Do the loved ones automatically get sent a copy of the autopsy and the CT scan or do they need to ask for it in order to get it?
Capt. MALLAK: When families are notified that they're loved one is deceased they are provided with a fact sheet about our involvement. And in that fact sheet is all the information they need to get a autopsy report. And they send that into our office and we provide them with the autopsy report. If they ask for the pictures or the CT scans, we provide them, but only upon request.
GROSS: So what information could, you know, a person who's not a medical expert get from the autopsy or the CT scan?
Capt. MALLAK: Many times the families are not able to view the remains at the funeral due to the severity of the injury. And weeks and months later they have questions about exactly what happened to my loved one and was that really them. And we provide that information in the autopsy report, not only a description of the wounds, but also how we identify them. We don't accept visual identifications - that another soldier says, yes, that's my buddy. We require fingerprint, dental, or DNA identification. And sometimes even families want beyond that. They'll want a picture of a tattoo or a picture of some part - a scar on the body - and we'll provide that to them to help them accept that yes, this was their loved one and they did die.
GROSS: I know that when you send out the reports to loved ones it includes a note saying don't look at this alone. Why do you give that advice?
Capt. MALLAK: Well, we care very deeply for these families and a lot of the information in these reports is very, very graphic, and reading them alone we've learned over the years is a very difficult thing for families. We receive feedback from families. They'll call us on regular basis and they'll say, yes, I really needed to do that with someone else, or I read it alone and I shouldn't have. That going through that and reading about exactly what happened can be very traumatic on a family and we're trying to help them.
The last thing we want to do is make it worse for them. So for them to have somebody willing to support them often provides that bridge and helps them get through that, so that they can understand the injuries and what happened, but still have that support system right there with them. It's worked over the years and the families have said that this is the right thing to do, so we continue to encourage them to have support around when they read our reports.
GROSS: What kind of information have you found that families find most reassuring as opposed to just upsetting when they read the autopsies?
Capt. MALLAK: Well, from the feedback that we've receive from families, the information about the identification is very important to them. They believe...
GROSS: To know for sure this is really my loved one. It's just like, you know, because isn't it, like you said, it's not like they're going to view the remains.
Capt. MALLAK: Not in all cases. In some cases the can and...
GROSS: Some cases they do? Mm-hmm.
Capt. MALLAK: ...and that's a mortuary decision. It's not our decision. That is made by the morticians and they make recommendations to the family. And the family can actually, if they want, view a set of remains even after being warned not to. They're entitled to do so. But when our mortuary colleagues recommend that you don't view the remains, it's for a reason.
GROSS: How much direct contact do you have with families?
Capt. MALLAK: Between 85 and 90 percent of the families have requested reports and probably 10 percent of that number call us back.
GROSS: What kind of questions do they usually ask?
Capt. MALLAK: They ask about the medical terminology. They ask about the wounds. They ask about the suffering, of course - is always a major topic. They also want to know about any natural diseases that we may have identified and whether that's something that their family should be monitoring. If the soldier had children or brothers or sisters, if we found something that's potentially a life-threatening condition that we didn't know about before they went off to Iraq or Afghanistan, that is also discussed with them at length, and how to approach their family physician with this information.
GROSS: Do you end up getting close to families who you talk to?
Capt. MALLAK: We provide them support as much as they need and they can call as often as they want. Do we get close to them? Do we get personal with them? No. We are there to support them, but like any physician, it's more of a physician-patient relationship than a personal relationship.
GROSS: Do families often feel this, like, bond with you, or the other people in your office who perform the autopsies, because you were the last people to see the remains, handle the remains or really, like, analyze the remains of their loved ones - and that makes you an important witness to what happened to their loved ones, so does that mean that the families feel a certain connection to you?
Capt. MALLAK: Not a large number, but there are a few that will call us repeatedly and even years later will just want to call and talk to us and -exactly what you said, that we were the last ones that had this chance to be with them. Other than the funeral directors, we're the ones that - we're they're final doctor. We're the ones that gave them their final - in some ways, it's a physical. And they will come back to us repeatedly just to talk about their family and - or talk about their loved one, or if there's something that's happened with the family, that they would come back and ask us if there's anything we could contribute to that. Say there's another death in the family, is there something that we can help them with? And we're available 24-7 for them anytime anywhere.
GROSS: When you say we, does that include you?
Capt. MALLAK: That includes me.
GROSS: So do you have a cell phone on 24-7 to deal with families?
Capt. MALLAK: Yes, I do.
GROSS: Can you tell us more about what those conversations are like?
Capt. MALLAK: We've learned that the death really for families has - their reaction has really no boundaries. And we - when we talk to them, we see every emotion that you can think of from being very upset to them being very thankful for us making sure their loved one did come home and is fully accounted for, to sometimes being very upset with the system, being upset with the way things are handled. But we're there and everybody in the casualty system and the Medical Examiner's Office, we just do our best to meet their needs.
GROSS: My guest is Captain Craig Mallak, chief of the Armed Forces Medical Examiner System. We'll talk more about autopsies of fallen soldiers after a break. This is FRESH AIR.
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GROSS: My guest is Captain Craig Mallak, chief of the Armed Forces Medical Examiner System. He instituted the policy of performing autopsies and CT scans on all soldiers who have died in Iraq and Afghanistan.
What does the CT scan show that a regular autopsy would not?
Capt. MALLAK: The CT scan is - takes approximately 3,000 cross-sectional X-rays in about five minutes. And our radiologists and our program manager are able to reconstruct the entire body then - and in three dimension, which can be examined in any angle. It can be looked at and turned. You can look at just soft tissue. You can look at just bone injuries. You can look at where the armor is because it shows up on the CT scans. So, it gives you a complete three dimensional reconstruction record that we will have forever for researchers, and designers, and developers for years and decades to come.
GROSS: So when you do the CT scan, it's of the soldier as they fell? In other words, they're wearing their clothing, they're wearing their armor, so that you could better understand what happened?
Capt. MALLAK: Yes. If there's no resuscitation we asked back in 2004 - much like our civilian colleagues in the medical examiner world do - that the body be left alone. That it be made safe, but after that, that it just be left alone and sent to Dover so that we can collect the same types of information in a forensic fashion that we were taught to do with - along with our civilian colleagues. And we couldn't do that if they took the bodies, took the clothes of, washed them down. Much of the evidence is lost then.
GROSS: Is the CT scanner you use different than the ones we would find if we were getting a CT scan for health problems in the states as civilians?
Capt. MALLAK: It's a little different. When we started this program back in 2004, we received a clinical CT scanner, which you would recognize. And if you saw our CT scanner right now, you wouldn't - looking at it you wouldn't notice any difference. But what we found is that a clinical CT scanner is not designed to do a full body CT scan at the highest resolution, repeatedly and in the course of a morning if we have four, five, six cases. And there were problems with components burning out. And we also found that the table was only - only moved five feet two inches and most of our military members are far taller than that.
And the opening through which the body passes through was also too small for the bodies to pass through, with the body armor on. And also some of our Marines and soldiers are very large and they didn't fit through the opening in the CT scanner. So our partner redesigned the CT scanner just for our needs and it was replaced a year and a half ago with one that's designed for forensic use.
GROSS: How is the body preserved until the autopsy can be done?
Capt. MALLAK: Working very closely again with our mortuary affairs colleagues, the bodies are collected as quickly as possible and then they're placed on ice and the temperature is monitored throughout the process. And it usually takes less than 48 hours for them to arrive back in Dover. Of course there'll be cases where bodies have recovered right away for a number of reasons. And there is some decomposition in those cases. But we try to minimize that and we work very hard to make sure that the decomposition is as minimal as possible so the family can have a viewing if they so desire.
GROSS: What happens when a soldier has been killed by an explosion and you get, say, body parts? And then later on you get another body part. Do you have a system so that you can analyze if a body part comes in after the rest of the body that is part of the same remains?
Capt. MALLAK: Yes, often the bodies are fragmented. And again, it's a family-driven process. If the medical examiner decides that the body is not complete, a letter is given to the family informing them of that and they are given the opportunity to decide whether they would like to be notified, if we're able to identify any additional portions that - we may have already, we have to run the DNA on or may come in later. And if we do make identification, the family is notified.
And when they're notified, they're asked again. If we find something else, do you want it to be notified? And that goes on as long as the family keeps saying yes, every time something is identified. And we've had portions identified weeks to months later. And some families say, no, that's enough, I don't want -we had closure, we're done. Other families say, no, I want to know every time you make an identification. And we do what the families ask us to do.
GROSS: My guest is Captain Craig Mallak, chief of the Armed Forces Medical Examiner System. We'll talk more after a break. This is FRESH AIR.
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GROSS: My guest is Captain Craig Mallak, chief of the Armed Forces Medical Examiner System. He instituted the policy of performing autopsies and CT scans on all soldiers who have died in Iraq and Afghanistan. In addition to the autopsies and CT scans that your office conducts on the men and women who have died in Iraq and Afghanistan, you've also consulted on cases of alleged torture and assault on detainees. Can you tell us a little bit about those cases?
Capt. MALLAK: Yes, again, using our civilian model we saw detainees the same as prisoners that would be in jail in any state in the union. And in most states they require anyone that's in the custody of the state to have an autopsy if they die while in the custody of that state. Using that model, anytime we had death of a detainee we use the same methods and do a complete forensic examination to either rule in or rule out any allegations of torture or mistreatment.
GROSS: So did you find torture or mistreatment?
Capt. MALLAK: We found injury patterns and whether it's actually torture or not is for the courts to decide. But we'll find injury patterns that concern us and we will give that feedback to the law enforcement agencies, such as the Army Criminal Investigation Division or the Navy Criminal Investigative Service. And then that information goes forward as they prepare for a prosecution of a possible assailant.
GROSS: So what kind of patterns have you seen?
Capt. MALLAK: You can see, you know, a variety of patterns from blunt force injury to gunshot wounds. And it doesn't always mean that it's torture. It just means that those patterns are there and those injuries are there, and at times those patterns had nothing to do with the American service members. It may have happened before they actually came into our custody. And that is how all to be sorted out by the investigative agencies, and it also includes the FBI's involvement in some of these cases.
GROSS: I think your office had to I.D. the bodies of Saddam Hussain and his two sons, is that right?
Capt. MALLAK: Yes, ma'am.
GROSS: Can you talk a little bit about how that was done?
Capt. MALLAK: Well, when the two sons were killed we were called to Iraq and we did our examinations and we took a forensic dentist with us. And they actually had dental records and we are able to through the dental records make identification on them. And then we collected, of course, DNA samples, like we do on every case, and we had those profiles. And when Saddam Hussain was captured we had his son's DNA profiles, which we were able to compare with that of Saddam Hussein and able to match that up.
GROSS: And I guess it was actually really important with Saddam Hussein because he had body doubles. So it was always possible that the person who was discovered was really a body double who was hiding out as a decoy.
Capt. MALLAK: That was a possibility and that's why we, our DNA ladder is the gold standard in the world, and we were able to turn that case round very quickly so that the leadership in the government and the military had a positive identification.
GROSS: So do you do the hands-on autopsies or do you just oversee other people doing them?
Capt. MALLAK: I don't do as many as the rest of the staff do. But I still do autopsies on a regular basis to maintain my skills and to maintain that sense of the importance of the mission.
GROSS: Are there families who ever ask that you don't perform an autopsy because they think that the autopsy will somehow desecrate the body or violate their religious views about death and the body?
Capt. MALLAK: We have very few - it's surprisingly few that request that we don't do our examination, and we talk with them at length and explain to them exactly why we're doing what we're doing. Usually that works out just fine. Sometimes, once in a great, great while - I'm talking less than handful cases since 2002 - it's had to go beyond that, where we've had to do extensive counseling with the family and had other types of professionals involved. If they have a religious objection, we provide religious support at Dover. If they would like a certain type of clergy there while we're doing our examination or there are certain limitations that some religions have on autopsies, we'll observe all of those and we've done our best to meet all those concerns of the family, and to date it has not been a problem.
GROSS: Is it hard for you to not only be around so much death, but this is a death caused by war, which is some ways the worst of humanity? So is that hard, and if so, what you do to counteract that, to keep yourself sane?
Capt. MALLAK: We view these young men and women as the very best that the United States has. They have volunteered their service in the defense all of us and they deserve to be treated, whether alive or dead, with the best care possible, and their families deserve our best to bring them the answers that they deserve, and that's what drives us every day, just keeping that focus. If we lose that focus, that's when it's time to leave.
GROSS: Do you feel like you've been changed in any fundamental way or that your view of death has been changed in any fundamental way from doing the work that you do?
Capt. MALLAK: I think doing this work for anybody, it does change you over the years. There's no way for not to. I don't think it's necessarily a bad or good way, just that as this becomes part of your life there are things that you look at differently, there's things that you appreciate more. When I leave in the morning from home I always make sure I'm on - my wife and I, we never leave on sour terms, where everything is fine when I go off to work or she goes off to work because we understand how fragile life is and that we may never see each other again. We know the chances are small but we'd never want to take that chance.
GROSS: Captain Mallak, thank you so much for talking about your work with us. I really appreciate it.
Capt. MALLAK: You're welcome ma'am.
GROSS: Captain Craig Mallak is chief of the Armed Forces Medical Examiner System.
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