1.2.1. History and definition of terms
The term autopsy also referred to as “post-mortem examination”, “necropsy”, “obduction” and “autopsia cadaverum” originates from the Latin language and denotes to “open, cut/dissect”. Another origin is from two Greek terms “aut” (self) and “opsie” (to see, to conduct a personal inspection) – autopsy therefore, refers to the opening/dissection of a cadaver to see for oneself, through observation, the cause of death or the nature of disease contrary to hearsay. Autopsy practice has been in existence since over 3000 years ago. It however became standardized during the Renaissance period in Europe (1,2) when the link between clinical syndromes and postmortem findings was established by Herman Boerhaave (3).
The autopsy rates are currently on the decline compared to the 19th and 20th centuries when autopsy practice was at its peak. This can be observed from the current rates of less than 5% of all deaths (4).
A survey by Brinkmann et al. showed that only 46,000 autopsies – 5.3% of all deaths in Germany were autopsied in 1999, making the autopsy rates in Germany lower compared to other European countries such as Great Britain (17.3% in 1999), Sweden (22% in 1992), Finland (31.1% in 1992) and Denmark (16% in 1992) (5). The survey also revealed that between 1994 and 1999, the frequency of clinico-pathological autopsies in Germany decreased from about 4% to 3% of all deaths while the frequency of medico-legal autopsies stood at 2% with marked differences between the different German states. The state of Hamburg particularly, recorded 20,000 deaths between 1994 and 1999, and among these, the autopsy frequency for clinical-pathological autopsies was 12.3% and 6.0% in 1994 and 1999 respectively indicating a 51,3% decrease in the frequency, whereas the rates for medico-legal autopsies were 1.5% and 1.5% in 1994 and 1999 respectively (5). The decline in the autopsy rates has in the past been attributed to lack of clarity about the legal position regarding clinical or scientific autopsies (6). The state of Hamburg introduced a new law in 2000 regulating clinical/scientific autopsies, and currently, three categories of autopsies are differentiated (7) :
• Clinical autopsy
• Anatomical autopsy
• Medico-legal autopsy
Other types such as private autopsies can also be performed in cases where there is particular interest – this can be from the family of the deceased who wish to have the cause of death determined or control of infections by the health authorities, etc.
Refers to the dissection of a body or body parts in anatomy institutes with an aim of teaching and research purposes concerning the build of the human body. The autopsy should be done under the watch of a qualified physician or the administration of the training institution where the training, teaching or research is being conducted. Importantly, the deceased person should have, before his/her death, consented to the dissection, and in addition, a complete external examination should have been conducted and a natural death confirmed. It should be noted however that, an anatomical autopsy is not meant to establish the cause of death.
This kind of autopsy serves to establish the cause of death, quality control of the existing diagnostic and therapeutic interventions as well as supporting the medical practice through teaching, research and epidemiology aimed at better care for the survivors. Prior consent from the deceased should have been obtained before death or in other cases; consent can be got from the mandated caretakers of the deceased before such an autopsy can be conducted. It is worth noting that a total of 36646 and 27147 clinical-scientific autopsies were done in Germany in 1994 and 1999 respectively (5)
A medico-legal autopsy is done at the request of the local state prosecutor’s office in death cases in which foul play or involvement of another party in the death of an individual is suspected. In all cases in which the cause of death cannot be determined, a medico-legal autopsy is done. In a nutshell, a medico-legal autopsy serves to help explain a legal question surrounding the death in question e.g. is the manner of death natural, unnatural or unascertained? Was someone else involved? What were the circumstances leading to death? Therefore, in addition to the results and findings of the autopsy, other findings such as those from the crime scene also play a big role in helping to determine what might have caused the death.
The medico-legal autopsy report should be as detailed as possible so as not to miss even the slightest of findings, which may later play a big role in determining the case. It is for this reason that standardized autopsy procedures as well as autopsy protocols have been devised.
The procedures for a medico-legal autopsy according to national and international guidelines should always include:
• External examination: This part involves the complete and systematic examination of the body. It should clearly detail features on the body such as clothing, age, height, skin color, body build and special characteristics such as tattoos and scars. It should also describe the post-mortem changes like rigor mortis and post mortem lividity, putrefaction or other environmentally-induced changes. Visible injuries on the body should be detailed, clearly documenting any foreign material seen on the body as well. Swabbing of body orifices should also be done prior to commencing the autopsy for the recovery and identification of biological trace evidence. Where necessary, complementary investigations such as imaging should also be done prior to dissection of the body.
• Internal examination: the internal examination should follow a systematic layer by layer opening of all the body cavities i.e. head, thorax and abdomen, and where need arises, the vertebral canal and joint cavities should also be examined. It should be emphasized that, once the body cavities have been opened, all organs and soft tissues should be sliced according to established guidelines and all findings clearly described in detail. The weight of all major organs should also be recorded. Sampling is case-dependent even though samples for histology, peripheral blood (for drug, alcohol and genetic identification analyzes), urine and gastric contents should be collected at the minimum, for every case.
The autopsy report, once the autopsy has been completed, should entail all the findings in a “clear, accurate and permanent document”, and should be comprehensible not only to doctors but also non-medical readers. Evaluation of the significance of the findings should also be given at the end of the autopsy in a medical-legal expert opinion (8).
1.3. Problem statement and study objective
The number of persons with foreign nationalities migrating to Germany particularly to the State of Hamburg has continued to grow over the years (9). Around 7.2 million persons (8.5% of the general population) were registered as foreigners in Germany at the end of 2010, eventually growing to 10.6 million- 12.8% of the general population by the end of 2017. Among these, the number of persons originating from Africa accounted for only 0.65% of the total population in Germany (10). In 2005 alone, 77% of the immigrants were estimated to be younger than 50 years of age while the values were 67% (males) and 60% (females) for the German non-immigrant population. Altogether, 78% of the population with foreign nationalities were in the 15-64 years age group in contrast to 63% for the German population (11).
Immigrants in general, have been shown to frequently suffer from infections and parasitic illnesses, of which they are also most likely to die from (12). For example, it has been shown that, the mortality associated with TB infections was almost 100% higher in immigrants older than 65 compared with non-immigrants (13). Sickle cell disease, well known among the important risk factors for childhood stroke has also been shown to be more prevalent in black children than in children from other ethnicities (14).
The prevalence of Helicobacter pylori infections among middle-aged adults has also been shown to be over 80% in many developing countries compared to 20 to 50% in developed countries thereby emphasizing a strong correlation between the overall prevalence of Helicobacter pylori infections and low socioeconomic conditions (15). This also explains the relatively higher frequency of gastric cancers and gastritis to be expected in immigrant groups living in Germany compared to Germans (16,17) . On the other hand, cardiac and circulatory-related illnesses and deaths have been reported to be less in all immigrant groups than in the German population (13,18,19) .
Worth noting also, is that a number of studies have shown that immigrants are at increased risk for developing stress-related illnesses and conditions due to the unusual climatic changes, as well as new social and cultural challenges they are subjected to (11,20) . In the long-run, these lead to increased risks for suicide, road traffic accidents as well as other kinds of accidents among the immigrants compared to non-immigrants (21,22).
Sudden Infant Death Syndrome (SIDS) which is the single leading cause of infant deaths beyond the neonatal period (23–25) has been shown to be relatively more frequent in dark-skinned babies for all birth weight groups compared to white and Hispanic babies (26) . In one study to determine the SIDS rates according to birth weights by Black et al. the SIDS rate per 1000 was 16.3 for black infants compared to 5.5 and 3.8 in whites and Hispanics for the less than 1500 gram – birth weight group respectively. Higher SIDS rates in black infants were also noted in other age groups i.e. 1501-2500 grams as well as the more than 2500 gram- birth weight group (26). Grether and Schulman also noted that race and ethnicity of the infant played a major role in the number of SIDS cases in California, where black infants were the second most affected group with an incidence of 2.8 per 1000 compared to Anglo (1.5), Hispanic (1.1), Chinese (1.5) and Japanese infants (1.8) (27). Another study by Veelken et al. showed that the overall incidence of SIDS in the city of Hamburg, Germany was 2.3 per 1000 live births with 82% of all infants and 100% of preterm infants dying within the first 6 months of life (28).