Is Death a Health Issue?

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Is Death a Health Issue? Disposal of the Dead
Post-Disaster
Peter Harvey
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• International news headlines within three days of
  the recent earthquake in Bam, Iran

Mass graves dug in Iran for earthquake dead
Disease fears as Iran death toll grows
Race against disease in Iran
Epidemic fears loom
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• Selected quotes from international news reports
  on the Bam earthquake

Our main worry is the health problem, a Red
Crescent worker named Ali said . We are trying
to bury as many people as we can to prevent it.
If we cant bury all of them by Tuesday it will
become a major problem because disease will
spread to Kerman and other cities.
Hamid Marashi, a UNICEF Iran communication
officer said the shallow and poorly prepared
graves may still fail to prevent epidemics and
will cause serious health problems in the
future.
The real fear for Bam now is epidemic and
disease. Bulldozers are being used to dig
trenches in the corner of the cemetery to bury
the dead as quickly as possible.
Iranian volunteers raced on Monday to dig graves
for thousands of earthquake victims to prevent
outbreaks of disease - or worse, an epidemic.
Victims are being buried as quickly as they are
pulled from the rubble to prevent the spread of
disease.
The smell of death surrounding them, volunteer
gravediggers, protected by inoculations, toiled
to try to prevent disease spreading from the dead
to the living.
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• The myth that dead bodies cause a major risk of
  disease, as reiterated in all large disasters, is
  just that, a myth.
• (PAHO, 1999)

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Presentation overview

• Dead bodies and associated risks
• Management issues
• Disposal options
• Case studies
• Key measures and recommendations

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The dead post-disaster

• In many scenarios, the management of corpses is
  based on the false belief that they represent an
  epidemic hazard if not immediately buried or
  burned.
• The primary problems and risks associated with
  dead bodies are social and political, not
  health-related.

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Death and disease

• A relationship between corpses and epidemics has
  never been scientifically demonstrated or
  reported.
• If people have died from the direct effects of
  war, famine or natural disaster then the risk of
  infectious disease is negligible.

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Health risks

• Epidemics are not caused by undisposed corpses
  but where an epidemic already exists, the
  disposal of the dead may become a more hazardous
  issue.
• Where the person has actually died from typhus or
  plague, the body may be infested with infected
  lice or fleas which can transmit these diseases
  to other individuals.
• A person who has died from cholera or ebola may
  pose considerable health hazards to those in
  direct contact with the corpse.
• Such situations are not common.

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Water-related disease

• Contamination of water sources and the resulting
  transmission of infection may occur in a very
  limited number of cases when bodies are in
  contact with the water system and transmit
  gastro-enteritis.
•  Diseases transmitted by mosquitoes such as
  malaria and dengue fever are NOT associated with
  the presence of dead bodies.

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Groundwater pollution

• Pollution of groundwater by buried corpses is
  rare.
• Burial sites produce dioxin and furan emissions
  which are potentially highly hazardous to humans
  but there is little evidence of resulting
  groundwater contamination.
• Risks from embalming fluids, such as
  formaldehyde, entering the groundwater are slight
  since 4 per cent formaldehyde solution is usually
  used and most of this degrades in the body and
  soil before reaching the water table.

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Air pollution

• Air pollution can be considerable where large
  funeral pyres are built this produces smoke
  hazards and air-borne dioxins.

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Mental health

• Perhaps the biggest risk associated with dead
  bodies is that to the mental health of the
  affected population. This includes the trauma of
  searching for survivors and retrieving corpses,
  as well as the unintended social impact of the
  precipitous and unceremonious disposal of bodies.
• The presence of a large number of corpses
  following a disaster is likely to cause fear and
  uncertainty among the affected population. It is
  essential that this is not exacerbated by
  inaccurate information linking dead bodies and
  infectious disease.

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Mental health

• Observation of the dead can be deeply disturbing
  and the odours produced by decomposing corpses
  may be even more so. It is therefore important
  that corpses are collected quickly and morgue
  facilities are provided if bodies cannot be
  identified and buried or cremated fairly rapidly.
• In most situations, the cultural obligation to
  take care of dead bodies and the mental health
  consequences of open mass graves and uncollected
  corpses should be given priority over potential
  disease transmission.

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Management issues

• Identification
• Depending on circumstances, the recovery and
  identification of the bodies of family members
  may be the primary concern of survivors.
• Provision should be made for monitoring deaths
  and funerals to record mortality data and to
  issue death certificates where appropriate.
• When those being buried are the victims of
  violence, forensic issues should be considered.

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Morgues

• In most situations it may be appropriate for the
  family of the deceased to keep the body after
  death to conduct a traditional wake prior to
  burial or cremation.
• Where there are many casualties, or where there
  is an epidemic, it may be necessary to set up a
  mortuary which should consist of
•  a reception room a viewing room
• a storage chamber for bodies not suitable for
  viewing and
• a room for records and storage of personal
  effects.
•  Ideally, bodies should be stored at 4oC but this
  is rarely possible.

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Protective clothing

• In most situations the family will take care of
  the corpse and will not require special clothing.
  
• Gloves and overalls should be provided to those
  handling dead bodies from epidemics and bodies
  with open wounds. High hygienic standards should
  also be adopted.
• Nose masks may be required to minimise the odour
  effects of decomposed bodies.

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The use of lime

• Disinfection with lime (or chloride of lime) is
  largely superficial, does little to remove
  infectious pathogens, and is hazardous to those
  using it.
• The provision of appropriate protective clothing
  to those handling the dead is likely to be more
  effective in epidemic cases.
• Where appropriate, chlorine solution or medical
  disinfectants can be used by trained people to
  disinfect areas which have been in contact with
  infected corpses.

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Disposal options

• Burial
• Preferred disposal method in most situations
• Cremation
• A cultural preference not a health requirement

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Mass disposal a last resort

• Mass disposal should be avoided if at all
  possible.

Family and friends demand the chance to identify
the victims of the 1985 Mexican earthquake,
expressing opposition to common graves.
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Burial

• Burial sites should be determined through
  consultation with the affected community and
  local authorities.
• Ideally, an area of at least 1500m2 per ten
  thousand population is required.
• The use of the cemetery should be carefully
  managed. Where there are different religious
  groups within the affected population it may be
  necessary to provide separate burial areas.
• Graves should ideally have a covering of soil of
  at least 1.0m and the base should be at least
  1.5m above the groundwater table.

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Cremation

•  The primary constraint concerning cremation is
  the availability of fuel. It is estimated that a
  single traditional cremation in India requires
  approximately 300kg of firewood. Cremation of
  large numbers of bodies can have a significant
  detrimental effect on the environment.
• Experience is essential to ensure that corpses
  are cremated at sufficient temperature.
•  Cremation can cause extreme smoke pollution
  which may contain harmful dioxins, especially
  where large numbers of bodies are cremated at the
  same time. Mass funeral pyres should be avoided
  where possible.

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Orissa cyclone

• Priority number one burning of dead bodies. The
  dead bodies cannot be disposed of fast enough.
  The drinking water is contaminated, the danger of
  epidemics grows dramatically. NGO
  sitrep
• Officials have stepped up efforts to cremate
  bodies which are poisoning the water supply.
  There has already been an acute outbreak of
  gastro-enteritis (29 dead) and there are fears of
  typhoid and malaria epidemics. BBC
  report

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Orissa cyclone

• There is no more mass cremation. Whenever we see
  a body we cremate it. There is no time to do the
  cremation in a systematic way.
• Local resident

Mass cremation following Orissa cyclone, 1999
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Rwanda genocide

• The Rwanda genocide is perhaps one of the few
  cases where mass burial could not be avoided.

• This was due to the absence of surviving
  relatives rather than public health concerns.

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Papua New Guinea tsunami

• The water in the lagoon is contaminated with
  dead bodies and disease will soon become a major
  problem.
• Government official

Rescue workers retrieve the body of a tsunami
victim out of a pool in the middle of what used
to be the village of Sissano in northern Papua
New Guinea.
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Bam earthquake

• Islamic requirement for same-day burial led to
  mass graves

• Risk of disease most commonly stated reason for
  urgency
• No time for ritual washing of corpses but large
  scale disinfection
• Many relatives were given no opportunity to
  identify bodies prior to disposal

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World Trade Center disaster

• Only 47 bodies remained unidentified among nearly
  2,700 fatalities.

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Socio-cultural issues

• In general, the cultural practices and needs of
  the families of the deceased should be given
  priority over public health concerns.
• The process of mourning and burial or cremation
  will be highly significant and emotional to the
  family and friends of the dead person. People
  often expend scarce resources on funeral rites
  and graves, and where this is their wish it
  should be respected.
• Memorials may help heal wounds and energies
  poured into this may speed up the emotional and
  physical recovery of the community.

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Measures for epidemics

• For deaths arising from epidemics (typhus,
  cholera, ebola etc.) it may be necessary to limit
  funeral gatherings, ritual washing of the dead
  and funeral feasts.
• Burial or cremation should take place soon after
  death and near the place of death, to reduce the
  spread of infection.
• It is advised that bodies are placed in body bags
  (if available) prior to burial, but contact with
  corpses should be minimised and embalming should
  not be carried out.

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Post-disaster measures

• Cemeteries or cremation facilities should be
  planned for and provided early on in an
  emergency, in consultation with members of the
  affected population.
• Lack of acceptable funeral facilities and
  procedures may leave social issues unresolved,
  which may contribute to the overall grief of
  those involved, causing rather than reducing
  trauma.
• The collection, disposal, burial and/or cremation
  of corpses requires important human and material
  resources which should be allocated to the family
  and friends of the deceased where possible.

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Key recommendations

• Give priority to the living over the dead
  (provide services and facilities for the
  survivors first)
• Promote the identification and tagging of
  corpses
• Provide accurate information concerning the risks
  associated with corpses
• Do not promote mass cremation of bodies
• Do not support mass burial of unidentified bodies
  in large graves
• Conserve fuel and resources
• Respect the wishes social customs of the
  families.

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