One by one, between 1949 and 1968, each of the 10 children Marie Noe bore died. One was stillborn. One died at the hospital just after birth. And the others expired at home, just infants, in their cribs, where Noe said she found them blue and either limp or gasping. Doctors, including some of the most respected pathologists of the time, could find no explanation for the eight crib deaths. Indeed, the medical community came to recognize that thousands of seemingly healthy infants inexplicably died in their beds each year, and they coined the name Sudden Infant Death Syndrome, or SIDS, for these cases.
Eight unexplained deaths in one family do not sit easily. We expect more from science, doctors, and cops. On Aug. 4, Philadelphia District Attorney Lynne Abraham seemingly satisfied our expectations when she cited new medical evidence to allege that Noe, now 70, had smothered the children with a pillow. "Science," Abraham told the Associated Press, "has been solving old, unsolved cases." She charged Noe with eight counts of first degree murder.
Abraham's claim puzzled me. How did she determine the deaths were homicide and not SIDS? SIDS is not really a disease but rather the name we've given to one of the great medical mysteries of our time: Any sudden infant death that remains unexplained after a complete post-mortem investigation is defined as SIDS. Typically in SIDS cases, a previously healthy baby is found dead in bed. No cry is heard from the infant prior to its death. The child may be found with clenched fists or frothy, blood-stained fluid issuing from the nose and mouth. Although 90 percent of SIDS deaths occur by six months of age, older infants can die spontaneously and unexpectedly as well.
One early SIDS theory that babies simply stop breathing has been discredited. Two suggestive findings are that sleeping on soft bedding and sleeping face down both increase a baby's risk of sudden death. A successful campaign to get parents to put babies to bed on their backs or sides has been associated with a 38 percent drop in SIDS deaths over four years. Perhaps SIDS will turn out to be a kind of freak accident in which babies, unable to turn over, are smothered by their own bedding. The findings raise questions about how in the world you could accurately distinguish suffocation from SIDS--especially in the Noe cases in which the original autopsies showed no marks of force, and the corpses are probably now nothing but bone. Forensic pathologists and child abuse experts I contacted confirmed that there is no distinctive autopsy finding or new test that could distinguish SIDS from homicide by suffocation.
So what was the basis for charging Noe? An official close to the case who requested anonymity admitted that there was no evidence that supported the charges of homicide. The doctors involved simply reviewed the old medical evidence. Had the previous pathologists missed physical signs of suffocation? No, the official said. It appears that the critical factor was the pattern. Eight deaths in one family was highly suspicious, and Noe was the only person present when each of the children died. (The district attorney reopened the Noe cases after a March Philadelphia magazine story about them.)
In child abuse cases, science often can only provide circumstantial evidence. Occasionally, we doctors find convincing evidence of abuse: cigarette burns, X-rays showing multiple fractures of varying age, bruises that trace the outline of a coat hanger, a stockinglike burn suggesting a foot plunged into and held down in hot liquid. However, most cases do not come with such obvious signs. In deciding whether to sic the department of social services on a case, we have only vague indicators to rely upon. For example, according to guidelines used at Children's Hospital in Boston, any bruise, facial laceration, or long bone fracture in an infant is considered evidence of possible abuse. In the end, doctors look for the parents to tell us much more than any physical evidence can.
Not long ago, my year-old daughter was playing unsupervised in an adjacent room when suddenly, she screamed. My wife found her lying on the ground, her right arm bent midway between the elbow and the wrist as if she had an unnatural extra joint. As near as we could figure, it seemed she had tried to climb onto our couch, our 2-year-old son had pushed her over, and her arm had got caught in the slats. As she fell, the bones of the forearm broke in two. When I took her to the hospital, I was grilled by three different people asking me over and over again, "Now, exactly how did this happen?" It was, I knew, a suspicious story--an unwitnessed fall resulting in a bad fracture. The doctors were looking, just as I do when I see young trauma victims, for any inconsistencies or changes in the story. It's easy for parents to feel self-righteous when doctors ask questions as if they're cops, but as advanced as medicine has become, questions are still our main diagnostic test for abuse.
Ultimately, I must have allayed any concerns. My daughter got a pink cast, and I took her home without incident. I couldn't help but think, however, that my social status played a role in all this. As much as doctors may try to avoid it, when we decide whether to involve officials in a case, social factors inevitably play a role. For example, we know that single parents have almost double the risk of being abusive, poor families almost 16 times the likelihood. One-third of crack-using mothers are found to abuse or neglect their children. (Race, by the way, is not a factor.)
In the case of Noe, these factors played to her advantage. She was married, middle-class, respectable. But the fact of eight deaths must mean something, right? As one coroner involved in the case said, repeating a maxim that has gained currency among pathologists, "One SIDS death is a tragedy. Two is a mystery. Three is murder."
The real answer, however, is that science can't tell us what happened beyond reasonable doubt. Bucking his colleagues, Pittsburgh Medical Examiner Cyril Wecht says that multiple SIDS deaths in one family do not automatically mean murder. The numbers certainly make the Noe deaths suspicious. After all, experts now believe that losing one baby to SIDS does not increase the likelihood that a family will lose another. However, Wecht points out, there have been cases of two and three unexplained infant deaths in a family in which homicide was ruled highly unlikely. Parents of SIDS babies have been wrongly accused in the past. And most troubling, as I said before, we don't know what SIDS is in the first place. We may have lumped several different diseases together in describing the syndrome. Perhaps multiple natural deaths in a family are possible.