Hospitals, nursing homes, and other medical facilities are potential hotbeds for covert violence, if for no other reason than the fact that many, many people die there every year. After all, patients typically check into a hospital because of serious illness or injury, and nursing homes are intended for those who need round-the-clock care. Although most of the sick and injured who seek medical care in the United States and elsewhere are treated and then released on the road to recovery, many others die on the operating table or in their hospital bed. Death is very much part of life in healthcare facilities, which unfortunately also makes them places where a killer can operate unnoticed for long periods of time without being discovered.

According to the Centers for Disease Control and Prevention (CDC), diseases, illnesses, and other naturally occurring medical conditions account for more than 90 percent of U.S. deaths each year, with a large proportion of those occurring in medical facilities (although at lower rates than in the past, as greater awareness of palliative care and concern for patient preferences have resulted in more people dying in their own homes; see Shmerling [2018]). Add to that U.S. deaths from accidents (the third-highest cause of U.S. deaths), assaults, and complications of medical and surgical care—many of which also occur in medical facilities—and the death toll seems staggering. With nearly three million total U.S. deaths a year (Xu et al., 2021) and more than 700,000 people dying annually in hospitals (Shmerling, 2018), it seems reasonable to estimate that at least one million deaths collectively occur in U.S. healthcare facilities each year.

The lack of clear data related to medical deaths is an enormous obstacle preventing better understanding of the covert violence that occurs in these settings. The CDC recorded 5,329 U.S. deaths in 2019 that were caused by “complications of medical and surgical care” (Xu et al., 2021). This category includes deaths from medical devices, adverse effects related to incorrect doses of therapeutic medications, and difficulties that arose during surgical or medical care. However, deaths from accidental overdoses of a drug or from drugs administered in error are excluded here, even when they occurred in a healthcare setting and/or the drugs were administered by a doctor or other healthcare professional.

Using the Nexis database of newspapers and newswires across the United States, we collected the following 37 cases covering a three-year period (June 2017 to July 2020) in which a death that was originally classified as something other than homicide was subsequently reclassified as homicide.

David Schlachet (Vincent and Dorn, 2020)

In July 2018, the superintendent at 48-year-old Lara Prychodko’s Manhattan apartment building found her mangled body in the trash compactor after an apparent 27-flight fall down the garbage chute. Authorities said she had an abnormally high alcohol level in her system and ruled it a “fatal accident.” A year later, however, New York City former chief medical examiner Michael Baden agreed to take another look. Finding indications that Prychodko had been strangled to death before being placed into the chute, as well as seeing little bleeding from lacerations sustained in the fall, the doctor concluded that the manner of death was most likely homicide. Moreover, Baden said the fact that Prychodko’s body was found topless would be unusual in an accident scenario and might be evidence that a struggle took place. At the time of her death, Lara and her estranged husband were in the midst of a highly contentious divorce, even though 55-year-old David Schlachet’s construction company continued to struggle after a 2016 bankruptcy. He had also been ordered to pay alimony and attorney fees to Prychodko, who was favored to gain child custody and a percentage of their millions of dollars in assets.

Karl Karlsen (Flynn, 2020)

Karl Karlsen’s first wife, 30-year-old Christina, died in a January 1991 house fire in Murphys, California. When the fire broke out, she was trapped in a bathroom behind a boarded-up window and had no way to escape the conflagration. Firefighters ruled the blaze accidental, and Karl Karlsen collected $200,000 in life insurance that he had taken out on Christina shortly before her death. He then moved with his children across the country to Varick, New York and remarried. In November 2008, he killed his son by making a truck slip off its jack while the 23-year-old was underneath it, crushing him to death.

Covert violence has always played an important role in supplementing conventional warfare. In 2016, for example, British special forces waged covert military operations in Yemen, Syria, Iraq, and Libya (Curtis and Kennard, 2019). However, two days after the U.K. Secretary of State for Defence stated that there were no plans to deploy troops to the Middle East, reports surfaced that British troops had secretly blown up an Islamic State vehicle carrying large amounts of explosives. Clandestine attacks by weaker operatives have also occurred, with devastating consequences in the United States, a country widely known for its military might. The most infamous examples include the December 1941 bombing of Pearl Harbor by Japanese forces and the September 11, 2001 attacks perpetrated by al-Qaeda terrorists; each resulted in the loss of thousands of American lives, many more injuries, and massive destruction of property.

Moreover, biological warfare has a centuries-long history around the world, as well as in the United States, such as the British colonists’ deliberate distribution of smallpox-infected blankets to Native Americans in the 1760s (Frischknecht, 2003). In modern U.S. history, the worst bio-terrorism attack—in terms of number of victims—occurred nearly 40 years ago in Oregon under highly unusual circumstances. In the early 1980s, several hundred followers of the Bhagwan Shree Rajneesh, the Indian spiritual leader who founded the Rajneesh movement, established a compound in northern Oregon, about an hour east of Portland. The Rajneeshees, as the followers were known, unnerved the residents of nearby Antelope (which has maintained a population under 100 since the 1940 Census). At first, it was because they all wore the same red clothing, participated in communal chanting and meditation, and demonstrated other odd forms of behavior. Later, it was because they began to outnumber the longtime residents and take over local politics. In fact, the city of Antelope was briefly renamed Rajneesh, Oregon, around this time.

When the Rajneeshees decided to aim even higher politically, they set their sights on the county seat of the city of The Dalles. The outnumbered group tried various strategies to sway the 1984 county election in their favor, including bussing in thousands of homeless people from around the United States who promised to vote for the Rajneeshee candidates—until that move was blocked by an emergency rule for suspected voter fraud.

On a beautiful Monday afternoon in the late fall of 2008, two men arrived at the Houston, Texas, home of their friend, a philosophy professor at the nearby university. They looked forward to the weekly discussions that focused on the theoretical traditions known as “Continental philosophy” and planned to continue their engaging dialog on Martin Heidegger’s Being and Time from the week before. A quick glance at their friend’s empty carport told the pair that the popular professor must be running late—most likely lingering to entertain the seemingly endless questions of his eager-minded students—but waiting together in the warm Southern sun was no bother. Plus, it wasn’t unusual for their friend to be a little late for a meeting now and then; he carried a heavier teaching load than most other faculty members in the department and always prioritized his students’ needs above all else.

After more time had passed, the men decided to call their friend’s cellphone to check on him. It wasn’t until that call went unanswered that they started to worry. Despite the professor’s absent vehicle, they thought that he still could be home and mused at how silly they would feel if they had waited outside all that time for no good reason. One of the men tried the front door and found it unlocked. When he tried to push it open, however, something seemed to be in the way. After managing to open the door enough to squeeze by and step inside, the man who had just been chatting and laughing with one friend while waiting for another, who had planned to while away the evening in debate and deliberation, suddenly realized that nothing would ever be the same again. There, at the bottom of the staircase just inside the front door, was the body of his friend—the beloved professor—now with a bluish tint to the skin and blood trickling on the floor behind his head. The man yelled to his waiting companion to dial 911.

The 54-year-old scholar was pronounced dead at the scene. An autopsy revealed the cause to be trauma to the back of the head—presumably from a tumble down the stairs—and the medical examiner ruled it an accidental death.

When thinking about violence against members of the mass media, the cases that tend to come to mind are those with the most famous victims, the most brazen perpetrators, and the most bizarre details. These cases involve mostly overt methods that frequently begin with an innocent-seeming initial contact before escalating over time to stalking behaviors and eventually one or more attempted or completed physical attacks, perhaps with a firearm or a knife. Indeed, numerous entertainers have been subjected to potentially violent stalkers. Media personalities are at particular risk for being stalked partly because of their high profile, but also because their role—whether they happen to be an entertainer, news anchor, radio morning show host, or politician—requires them to pander to an audience and sustain public attention (Wilson et al., 2018).

Many people have sent fan mail to their favorite celebrities and/or reached out to them on social media, and some die-hard fans pay exorbitant sums of money for backstage passes and meet-and-greet events with A-list stars. Very few would ever attempt to get closer than that, and rarer still are the handful of deranged individuals out there who develop unhealthy obsessions with famous people that may lead to dangerous—and sometimes deadly—consequences. Among the most notorious of these incidents are the fatal shootings of singer John Lennon in 1980 by an angry Beatles fan, of actor and model Rebecca Schaeffer in 1989 by an obsessed devotee, and of singer Selena Quintanilla-Perez in 1995 by the former president of her fan club. Several laws and other practices changed in the 1990s (particularly in response to the death of Schaeffer, who was shot in the doorway of her home after the killer obtained her address via California Department of Motor Vehicles records) that have helped to prevent more of these incidents, though they certainly still occur.

In a recent example, up-and-coming singer Christina Grimmie (who finished in third place on season six of The Voice) was fatally shot in 2016 by an obsessed fan while the 22-year-old signed autographs after a concert in Orlando, Florida. Stalkers have broken into the homes of Sandra Bullock, Selena Gomez, and Jennifer Lopez; have trespassed on properties owned by Kendall Jenner, Madonna, and Taylor Swift; and have sent unwanted letters and gifts to numerous others.

One finding from our exploratory study of reclassified U.S. deaths (see Chapter 1) suggests that the perpetrators and victims in cases of covertly committed murder are disproportionately more likely to have shared a familial or other close relationship compared to those involved in overtly committed incidents. Indeed, an established relationship with a would-be victim—especially if that relationship includes the assumption of trust—would be an advantage for a covert perpetrator. That is because covert violence often requires the perpetrator to have close access to either the intended victim or to an item that they would not hesitate to ingest or have in close proximity. While most people would be suspicious of food or drink that was left on their porch by an unknown person, they would likely put no thought at all into accepting a cup of coffee from a friend or eating a meal prepared by their spouse.

Related to the apparently higher incidence of covert violence within families and friendships is another finding from our study: that women appear to commit covert acts of violence at far higher rates than is reported in official data on violent crime. This may be explained, in part, because of an inverse relationship between women’s access to power and their access to family members and friends. The family happens to be the one social institution in which U.S. women are disproportionately deficient relative to men in all three types of power that are relevant to covert violence (that is, physical, economic, and personal). Economically, women in paid work still earn less than men on average (Aragao, 2023), and mothers are more likely than fathers to head a single-parent household (Livingston, 2018). These facts combined help to account for women’s higher rate of poverty compared to men (Semega, 2019).

While it may be pure mythology to depict our cave-dwelling masculine ancestors as clubbing their female companions before dragging them off by the hair, the contemporary version of the mythical caveman has its counterpart in reality. It is clear, however, that men’s greater-on-average capacity to physically overpower women is exponentially more dangerous when combined with traditional gender roles that legitimate male aggression and encourage female submission, a dynamic that still exists in many American families today.

Preventing covert violence is perhaps even more difficult than preventing overt forms of criminal behavior. To a large degree, this is because the covert version is often harder to detect and/or is easily misunderstood as something else. Enough cases of presumed accidental deaths subsequently turn out to be murders that we can reasonably assume that many acts of covert violence are either never discovered or never identified as intentional.

Some incidents remain in an indefinite state of uncertainty within the minds of officials. The Pepsi and Tylenol cases in Chapter 4 are perfect examples, as each implicates customers and companies in plots that they may or may not have initiated. Similarly, the 2001 anthrax attacks in the aftermath of 9/11 continue to generate significantly divided opinions among experts and members of the public as to their origins, with some accusing prominent scientists or the 9/11 terrorists and others promoting conspiracy theories that involve images of a deep state within the U.S. federal government. If those infamous incidents were never officially solved, then it would not be surprising to find that many lower-profile cases are missed entirely.

Unlike unsolved cases, in which the action is recognized as malicious even if the identity of the perpetrator is unknown or ambiguous, undetected covert cases produce nothing that appears to need solving. Compared to maliciously inflicted injuries and deaths, those that are deemed accidental, due to natural causes, or self-inflicted generally require much less (if any) investigation and follow-up. And once an official classification has been made, there are virtually no mechanisms in place for routine reconsideration. It often takes years of persistence from a victim’s friend or family member to convince an authority figure to take another look, and frequently that suspicious person must uncover some kind of new evidence before they find anyone who will listen.

There are also practical reasons for not investigating a death when the manner and/or cause appears to be obvious. Determining the exact cause of a death requires available and sufficient funding, as well as other limited resources such as the time and expertise of physicians and/or other scientists.