Overloaded Morgues, Mass Graves and Infectious Remains: How Forensic Pathologists Handle the Coronavirus Dead

Yves here. This post is literally morbid, but it still seemed important, given that I’d had one worldly colleague in New York City express incredulity that hospitals were having to use refrigerator trucks to store bodies of the coronavirus dead. She seriously thought the idea that medical centers (and presumably the city’s morgues) had run out of places to cold-store corpses struck her as media scare-mongering.

By Ahmad Samarji, Associate Professor of Forensic Science Education & STEM Education and the Assistant Dean of the College of Arts and Sciences, Phoenicia University. Originally published at The Conversation

Ahmad Samarji, a Lebanon-based scholar of forensic science, reports on the extraordinary challenges facing coroners and pathologists in outbreak zones, where governments have to take “very limited but essential choices” to avoid a dangerous pileup of dead bodies. This Q+A has been edited and condensed for publication.

What is the role of forensic pathologists in a pandemic?

Forensic pathologists are physicians who integrate law and medicine to determine the cause, mechanism, manner and time of a person’s death. Their everyday work has important legal, social and economic consequences for family members of the deceased and for the larger community.

During a pandemic, forensic pathologists are heavily involved in managing the crisis, either within their local communities or as part of a humanitarian mission working with vulnerable communities abroad.

Their role in these extremely challenging times is to ensure the proper management of dead bodies, minimizing the spread of the virus, and to guide authorities, hospitals and funeral directors about the “do’s and don’ts” of dealing with these bodies.

There is a general assumption in medicine that dealing with the deceased does not require the same urgency as working with an acutely ill patient, and normally that is true. However, in a pandemic like COVID-19, large numbers of the dead can quickly exceed local capacities if not managed in a timely manner.

With highly infectious diseases, it is urgent that the post-mortem procedures – from death, examination, certification, registration and release of the body to safe cremation or burial – flow as properly and smoothly as possible.

Are the bodies of COVID-19 victims infectious?

While a lot is known about the coronavirus family, much is yet to be understood about the transmission modes and effects on the body of SARS-CoV-2, the virus that causes COVID-19. We don’t know whether human remains are infectious, but the likelihood is high. So forensic pathologists around the world are urging governments to restrict viewing and handling of the body after examination is completed.

During the Ebola epidemic – which claimed around 11,300 lives in West Africa between 2014 and 2015 – handling of the dead was one of the main modes of transmission of the disease. So one of the lessons forensic humanitarians took from this experience – which is now being applied to coronavirus – was that untrained first responders should not be involved in handling human remains during outbreaks of highly contagious diseases.

Are cities with coronavirus outbreaks able to manage the dead safely?

With the death toll from coronavirus projected to exceed many hundreds of thousands worldwide, governments everywhere are scrambling. But health systems that have planned for pandemics – and allocated sufficient resources to manage them – seem to be in decent shape.

My colleague Dr. Ralph Bouhaidar – a consultant forensic pathologist at the University of Edinburgh – told me that in addition to spending long hours in the Edinburgh City Mortuary, he is closely collaborating with prosecutors, police, funeral directors and hospitals across Scotland to review, assess and update existing procedures for managing “excess deaths in a pandemic.”

Dr. Bouhaidar emphasized that an appropriate COVID-19 response does not “emerge from a vacuum.” Rather, he said, proper management of the dead is “the result of cumulative work and planning…to have an understanding of local capacities and study our resilience in dealing with such possibilities, whilst liaising nationally and internationally with colleagues to share knowledge and experiences.”

So far, with 4,565 confirmed COVID-19 cases and 366 dead, Scotland’s hospitals and morgue are not overwhelmed.

But there are grim reports from hard-hit cities – like New York and Guayaquil, Ecuador, for example – of coronavirus patients dying so fast that bodies are just piling up. Both cities are considering digging mass graves.

When national plans for managing dead bodies in pandemics are exhausted, it leads to the piling up of bodies, issues with storage and refrigeration, and decomposition. That, as a result, increases risk of infection across the community.

Under such conditions, local and federal governments have very limited – yet essential – choices to handle the volume of bodies.

They should allow for the certification of medical deaths due to COVID-19 by the treating clinician, without the need for a post-mortem examination, to enable a swifter flow of the deceased within the system. They must also set up temporary mortuaries big enough to accommodate thousands of bodies. British authorities, for example, are building a special COVID-19 mortuary at the Birmingham Airport to accommodate 12,000 bodies. And, yes, they may need to excavate mass graves.

All this must be done while ensuring a dignified burial for the bodies and proper labeling of the graves as required by international humanitarian law.

What dangers does the COVID-19 pandemic present for forensic scientists?

Despite all protective measures, forensic experts are at constant risk of exposure to this deadly virus. And when pathologists in hard-hit areas contract coronavirus, it intensifies a vicious cycle.

They must absent themselves from work for at least 14 days, and some will die. This worsens an already miserable situation with the handling of dead bodies and, as a result, threatens the health of the entire community.

Forensic scientists from the Red Cross are being sent into refugee camps, war zones and overwhelmed cities on humanitarian COVID-19 missions to provide pandemic assistance. In these places, the risk of contagion is even greater. The morgues they work in there most likely face shortages of staff with expert skills and appropriately equipped mortuaries.

Generally speaking, the forensic examination of a dead person doesn’t require highly complex equipment and machinery compared to other health specialties. Pathologists just need appropriate storage, personal protective equipment, basic dissection tools and specimen collection material.

But our work falls within a larger chains of events. Hospitals must have the capacity to identify the person, determine their cause of death, physically dispose of the body and work through the various legal complexities that these cases attract – and to do so swiftly.

You mentioned how forensic scientists learned about Ebola on the job. What are we learning about coronavirus that’s aiding the pandemic response?

The lessons from Ebola were reflected into the revised “Management of Dead Bodies following Disasters” manual, published in 2016 by the World Health Organization and International Committee of the Red Cross, that is now aiding governments and first responders worldwide in the COVID-19 pandemic.

Today, cross-disciplinary research is underway about COVID-19 that connects the knowledge of forensic pathologists with that of clinical medical practitioners, virologists and biochemists.

In Italy, for example, a study published March 26, led by 25 health professionals across fields, warned health care professionals and morgue staff about specific risks in handling COVID-19 patients and provided guidance for autopsies of suspected, probable and confirmed cases of COVID-19.

Such work, when replicated and carried out across various research teams and countries, will greatly assist in managing this global crisis, formulating an effective treatment plan – and potentially creating a vaccine.

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  1. Dom

    I’m based in Guayaquil, and judging from the number of people I know directly or indirectly who’ve died since the outbreak I’m certain deaths are being under-reported. Whether this is deliberate or just as a result of lack of testing is unclear, but it seems true that in some of the poorer districts people have had to resort to cremating their relatives in the street after bodies have been left uncollected for days.

    The following article sums up the reasons for the dire situation extremely well, but suffice to say Ecuador now desperately needs to reset its economic policies and free up the economy or there will be trouble in the near future.


  2. The Rev Kev

    I am wondering if morgues are also run on a minimal capacity. It cannot be that cheap running those refrigerated spaces so you would expect that only enough are installed to cope with what is expected in the same way that hospital beds and ICU units are as well. Sadly, mass burials are a sign that you have well and truly lost it which may be why New York is trying to avoid it.

    1. PlutoniumKun

      There can be a cultural issue too – in some countries they bury quickly, in others they don’t mind holding on to bodies. I remember the incredulity of the Irish side of my family when an English aunt died – we were told that the funeral wouldn’t be for a month as the vicar was on holiday and wasn’t around to give permission for the burial so my aunt was put on ice.

      1. Yves Smith Post author

        It was only a movie, but I remember the scene in Manchester by the Sea (Massachusetts coastal town) where a son goes unhinged because his dead father is being kept in a morgue all winter because the ground is frozen, so he can’t be buried until spring thaw.

        1. wilroncanada

          Yes. My father told me that’s what they used to do in Quebec (Eastern Townships). The same was/still is? true of at least parts of the Maritime provinces.

          1. Martin from Canada

            Same in Northern Ontario. You’ll hold the wake in the winter months, and then do the burial with the ground thaws, usually around the middle of May for where I grew up.

          2. HotFlash

            Same when my mum died in January in Michigan. Funeral was the normal 3-4 days, interment was spring. The cemetery has a freezer. It seemed odd, not having a grave to put flowers on.

        2. PlutoniumKun

          I guess thats a reason why so many US graves (unlike in Europe) are concrete lined. A few years ago at a family funeral in February in New York (Long Island) my Irish side of the family were openly wondering how on earth they dug a grave in such sub zero temperatures. It hadn’t occurred to any of us that it was a simple matter of just lifting the concrete cap.

          The funeral directors had diplomatically provided a cover so that the widow didn’t have to witness that her husbands coffin was fitting neatly on top of the one belonging to his previous wife.

      2. Dave

        Pu Ken: In upstate New York, they used to dig graves in the Fall to accommodate the expected number of burials over the Winter. I’m not sure if they still do that.

    2. Temporarily Sane

      It cannot be that cheap running those refrigerated spaces so you would expect that only enough are installed to cope with what is expected in the same way that hospital beds and ICU units are as well.

      Yep, spending money on hospitals and quaint public stuff is a horrific waste when you can invest in far more profitable ventures.

      It is exactly what you would expect in a neoliberal society that values profit over people, but it is by no means a self-evident conclusion.

      In fact, it’s because of this philosophy that healthcare systems and economies in the so-called “advanced” countries are all to varying degrees collapsing in the face of an entirely foreseeable public health emergency.

  3. PlutoniumKun

    I wonder too about graveyards. Traditional graveyards often have very unsuitable geology which can inadvertently lead to body tissues getting preserved instead of breaking down rapidly, or can result in biological matter entering groundwater. I believe there were cases of cholera spreading via plague pits contaminating well water.

    It varies by country of course, but the standards for modern graveyards assume a fairly standard rate of degradation – it might be a problem if there were a lot of bodies buried at once.

    Cremation of course is a sterile solution, but that can also lead to air pollution. I was once in an open air crematorium in Thailand when I noticed a pile of old car tyres in a corner. I asked why they were there and I was told that during the wet season, it was too hard to get wood to burn, so they chucked on a car tyre or two to get the temperature up. I’d hate to think of the air pollution consequences of a lot of bodies needing to be disposed of (also of course, in Buddhist ritual the body must be washed by hand, I wonder if this is a potential hazard).

    1. Anon

      Here is a brief description of the cremation of a deceased person in the U.S. :

      A cremation chamber, referred to as a retort, is an industrial furnace that is large enough to hold one body. Fire resistant bricks line the chamber and can withstand temperatures up to 2000 degrees. Modern cremation furnaces follow according to strict environmental and air quality standards. Natural gas, propane, or diesel fuel the furnaces. They are also automated and computerized.

      There was a time when the Catholic church wouldn’t permit ritual Mass to be performed for cremated parishioners. That’s probably now been rescinded.

    2. Rtah100

      “I was once in an open air crematorium in Thailand”

      Definitely a contender for best opening line. What is the backstory…? :-)

      1. PlutoniumKun

        I was just cycling past, saw some interesting looking buildings and stopped to have a look – a local with perfect English offered me a tour, simple as that! Its one of the joys of exploring places outside the tourist beat, you experience all sorts of serendipity.

  4. JTMcPhee

    Reminds me of what happened in 1995 in Chicago during a heat wave that literally cooked people (poor black, or other “ethnics”) in their slum apartments because they did not have air conditioning, or were living on the streets:

    “ ‘Cooked’: Edifying documentary sheds light on Chicago’s deadly ‘95 heat wave —
    Movie details how areas of minorities, the poor and the elderly suffered the most casualties.“

    Nearly 25 years later, the visuals and the stories are still shocking and horrific.

    Refrigerated food trucks rolling in to serve as temporary containers for literally stacks of bodies, because the morgue couldn’t keep up.

    The granddaughter of a victim recalling, “They just laid her on top of the other bodies, like she was a cord of wood.”

    Bodies laid to rest in a mass grave some 160 feet long, 10 feet wide and six feet deep.

    Government officials passing the buck, absolving themselves of blame — even attacking the medical examiner’s integrity.

    These atrocities did not occur in a war zone, or in a developing country. This all happened in the city of Chicago, in the summer of 1995.

    For those of us who were around for the Chicago Heat Wave of ’95 and were stunned and sickened as the death count rose deep into the hundreds, the new documentary “Cooked: Survival by Zip Code” is a jolting reminder of the tragedy, and a scathing indictment of the social conditions that allowed so many to die — with the overwhelming majority of victims being minorities, the elderly, the poor.

    For those who don’t know the story: You need to see this movie. …


    Nothing new in Neoliberalland…

    I happened to be at an army field hospital during Tet, and got to witness a GI drive up with a dump truck full of dead GIs and Marines, He backed up to the open area where the “graves registration” GIs were collecting dog tags and tagging-and-bagging the bodies. The driver raised the dump body, and out slid a pretty aromatic tangled mass of bloating corpses to add to the other piles…

    “Bring out your dead, bring out your dead…” https://www.youtube.com/watch?v=QcbR1J_4ICg

    1. lyman alpha blob

      As Yves noted, at this point mentioning the temporary morgues is likely media scare mongering. As you noted this is not unprecedented. Here’s another gruesome example – https://www.nbcnews.com/news/us-news/too-many-bodies-ohio-morgue-so-coroner-gets-death-trailer-n733446 – with an equally scare mongering headline.

      But despite the bodies stacking up from overdoses, those who dealt sickness and death to tens of thousands in the case of opioids are still walking around free. Nothing new at all in Neoliberalland.

      1. Steve in Dallas

        “With the death toll from coronavirus projected to exceed many hundreds of thousands worldwide”

        Scare mongering? Yes, when I ‘do’ the numbers, I have to agree…

        Assuming a USA population of 330M, an average life span of 75 years, and an equal number of deaths as births… 330M / 75 = 4 million Americans die per year. Also, ‘typical’ annual virus-related USA deaths of 40-50K… and as many as 200K American deaths in a ‘bad-flu-season’ (roughly 4-5x normal) is NORMAL.

        But notice the above quote says “many hundreds of thousand worldwide”. Worldwide? Hmm lets do those numbers… 7.5B / 75 = 100M people die every year. The USA population is roughly 1/20 of the world population so… 50K typical USA virus-related deaths X 20 = 1M typical world-wide virus-related deaths and 200K * 20 = 4M worldwide bad-flu-season deaths per year.

        So what does the author mean by “many hundreds of thousands”? He didn’t say “millions” (which ‘was’, and no longer is, what the ‘experts’ and ‘authorities’ were screeching when the panic started) . But if he had said millions then a fair comparison of how much this ‘new virus’ has ‘increased’ the death numbers would compare the typical/bad flu season numbers to the new-virus numbers. Bottom-line, 100K (or even 200K) ‘additional’ American deaths due to the new-virus would NOT be out of the NORMAL… and 2-4M additional world-wide deaths due to the new-virus would NOT be out of the NORMAL.

        Let’s take the numbers one step further… to the core issue… how many ‘additional deaths’ would it take to justify 30M Americans losing their jobs and a massive economic meltdown where the bottom 90% will again be systematically and methodically stripped of their wealth and the top 10% are again rewarded with trillions in cash to buy up all the depressed assets? Hmm… let’s be conservative and say that only ‘twice’ as many virus-related deaths as a bad-flu-season (i.e. a ‘super’ bad flu season with an ‘additional’ 200K American and 4M worldwide deaths) justifies a ‘pandemic response’ with extreme mitigation measures? OK, fine… lets save the people… but shouldn’t we demand that the ‘numbers’ be understood… AND accurate?

        So where are we now, halfway through the flu season when most virus-related deaths occur (OK… three months after the new-virus hit the streets)? Of the USA-pandemic-justifying-additional-200K-deaths we’re at 10K. Of the worldwide-4M-pandemic-justifying-additional-deaths we’re at 100K. Yes, of course, we have to consider that our mitigation measures have ‘dramatically’ reduced the death numbers (after all, let’s not forget have amazing our achievements are, which, as we all know, are only getting dramatically better, like Boeing aircraft!).

        At this point, for me, looking at the numbers, and looking at how the numbers are being presented by the ‘authorities’ and ‘experts’, I’m NOT at all convinced that, assuming no mitigation measures, this ‘new virus’ ‘would have’ doubled the ‘typical’ flu-season virus-related deaths (by 50K USA and 1M worldwide) let alone doubled the ‘bad-flu-season’ deaths (by 200K USA and 4M worldwide).

        As for this article’s subject of ‘managing the number of dead’… again you have to ‘compare’ the numbers. This article clearly attempts to give the impression that “hundreds of thousands” of worldwide deaths will overwhelm the systems. The USA normally manages 4M deaths per year and the world manages 100M deaths per year. Can it manage a 1% increase (e.g. half the population new-virus-infected with a 2% death rate!!!… with, of course, higher local concentrations where the virus is ‘raging’!!!)? Hmm… again, when I ‘do’ the numbers and ‘question’ how and by whom the numbers are being presented… this article, like many others, appears to me to be irrational, inappropriate, and irresponsible… i.e. “scare-mongering”.

        1. Basil Pesto

          It’s not clear to me why you chose to use an invented average lifespan as the denominator when trying to calculate how many of the US population die per year.

          The CDC provides this information for your country. The life expectancy in this US in 2018 was 78.7 years. The number of deaths was 2,839,205.

          I‘m not sure I’d trust you to crunch a potato chip, let alone the numbers.

        2. Ignacio

          This is exactly the kind of attitude that will almost certainly make things bad after episode 1. This line of thinking has to be eradicated. No matter how wise or unwise will be next movements after this but collaboration of the population at large will be very much needed.

    1. lyman alpha blob

      From the Miami Herald article linked to in the tweet –

      The government has identified 6,000 social media accounts, all working in unison, to spread false information. On some occasions, those accounts have managed to plant the stories more than 180 million times.

      Serious question for anyone who may be smarter than me about these things, which would be most everyone since I’ve never done social media. If someone is able to identify the fact that 6k accounts are all working in unison, why can’t they also determine who set up the accounts and publicly identify that person or persons?

      Back in the olden times of the 90s and early oughts before there was social media, it seemed that any time someone committed a crime, the authorities were able to almost immediately tell us what kind of stuff the perpetrator had posted online, even when they did so anonymously. Why can’t they figure it out now when there is presumably far less anonymity than there was 20 years ago?

  5. HAL

    One issue that might not be visible to a Scottish FP is that the US is suffering from a shortage of forensic pathologists. Since all FPs/Medical Examiners work for state and local governments, they are badly paid compared to almost any other medical specialty you could think of. Those still in the profession skew older, which means they have less time left working and also are at higher risk.

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