The images stayed long after the Ebola pandemic had seemingly passed. Hazmat suits, face masks, steel-toed boots and gloves. The burials conducted by solitary, unidentifiable figures on mounds of freshly dug soil.
The handling of the dead during the Ebola pandemic was one of the main modes of transmission of the disease. As the virus spread, so too did a marked mistrust of health officials — and the difficulty of safely and respectfully disposing of victims’ bodies.
For those people making a living among the dead, the Covid-19 pandemic has brought with it new yet oddly familiar safety concerns. Thus far, the living have been the focal point of the department of health’s pandemic-response plan, but details about what will happen in the event of mass fatalities have been scant — and with good reason.
Although much is known about the coronavirus family, there are still gaps in our understanding of transmission modes and effects on the body of SARS-CoV-2, the virus that causes Covid-19.
Micro-organisms are classified into four hazard groups on the basis of their ability to cause disease to humans, risk to laboratory workers, transmissibility to the community, and whether effective treatment is available. A hazard group (HG) one organism is unlikely to cause human disease; a hazard group four organism can cause severe disease and is a serious hazard. SARS-CoV-2 has recently been categorised as a HG3 organism joining the likes of rabies, polio, dengue virus, hepatitis virus B, C, D and E, and HIV.
Adapting to Covid-19
Mortuaries around the world have had to adapt their body-management systems, much like West African countries did with Ebola.
With Covid-19, we don’t know whether human remains are infectious. But the likelihood is high. As a result, forensic pathologists are urging governments to restrict viewing and handling of the body after examination is completed. And how bodies are handled postmortem — from death, examination, certification, registration and release of the body to safe cremation or burial — is important.
As early as February, Red Crescent Societies and the International Committee of the Red Cross (ICRC) had compiled and disseminated a guideline for countries, in a variety of languages, to assist them in the proper handling and disposal of bodies. The guideline is meant to provide a practical overview of key recommendations for the management of human remains.
Stephen Fonseca, a regional forensic manager for the ICRC for Africa, says death is an essential part of healthcare preparation — someone has to handle the deceased and they too need to be prepared for any eventuality.
This means everyone, from people doing the more social rituals of burials and cremations to those investigating causes of death, has to take extra precautions.
There are different safety measures that have to be taken. What the ICRC brings is forensic expertise and experience, having worked in disaster-management and conflict zones. Its guidelines are there to help any one — whether it’s a government, national society or community — with what should happen with human remains, as well as not to overreact, Fonseca says.
Though it has no authority on a governmental level, what the organisation is doing is trying to encourage a reasonable approach to body-management. “We are trying to balance all this without causing panic.”
Working with bodies
Professor Jeanine Vellema, the chief specialist at the Gauteng Forensic Pathology Service, deals with bodies all the time and is pragmatic about Covid-19. “We deal every day with infectious diseases. This is not new to us.” Her department deals with unnatural deaths, but the pandemic has hardly changed how she and her colleagues carry out their work. Accustomed to dealing with contagious pathogens like tuberculosis, Hepatitis B, and HIV, Vellema reiterates that they are prepared.
The proper use of protective personal equipment, coupled with stringent hygiene practices before the pandemic, has made the transition to working with cadavers that were potentially exposed to Covid-19 much easier.
Vellema has written a guide for how staff can deal with bodies, while avoiding infection. The same rules apply as with other bodies. Any body suspected of dying of or with a Covid-19 infection must be decontaminated and disinfected before being placed in two sealable body bags.
Despite this, the job is still safer than public spaces and Vellema drily adds: “We are more likely to contract the disease in a supermarket than here.”
According to the National Institute for Communicable Diseases, people who die of Covid-19 should be cremated. But if cremation is not possible, burial must follow strict procedures: the body must be placed in a leak-proof triple body bag and then buried in a nontransparent coffin.
In a statement last month, the South African Cemeteries Association said the low number of crematoriums in the country make cremation a difficult option. In its guidelines for “the preparation of mass burials and cremation of Covid-19 victims”, the association said: “In anticipation of the increase in the death rate, municipalities are recommended to put plans in place if this has not already been done.”
Alone on the final journey
Drone footage from the United States of caskets being lowered into Hart Island’s trench-like graves is a grim reminder of the potential toll of the coronavirus. Like New York’s potter’s field, Hart Island has been a burial site for the densely populated city’s unclaimed dead for more than a century. The coronavirus outbreak in the city has led to a surge of burials on the island, and space is limited.
Guayaquil, in Ecuador, was unprepared to confront the coronavirus dead. The port city gained infamy when videos surfaced showing dead bodies left in the city’s streets after morgues and funeral homes were overwhelmed.
Many families made the choice to put loved ones outdoors for fear of infection and because the smell of decomposition was overwhelming. In the confusion, relatives of the deceased could not find their loved ones’ bodies, further compounding the grieving process.
In South Africa, deaths related to Covid-19 have passed the 200 mark, and are not overwhelming the burial system. But municipalities have warned for years that they are running out of burial land. The Covid-19 outbreak in the country will put pressure on the authorities to respond to this need.
Mass graves are the quickest solution. But they come at a social cost.
The Red Cross’s Fonseca says the organisation “highly discourages” mass graves because they are often a “demonstration of poor planning by authorities” and show “a disregard for the wishes, cultural/religious rites of families and communities”.
Fonseca says instead that communities have to be included in creating funeral plans, so the mourning process is taken seriously.