A Grisly but Essential Issue

By Ceci Connolly
Washington Post Staff Writer
Friday, June 9, 2006

They brought in steam shovels to dig graves. Caskets were rented -- just long enough to hold a brief memorial service -- then passed on to the next grieving family. The death toll of the 1918 flu pandemic was so overwhelming that the military commandeered entire trains to transport dead soldiers; priests patrolled the streets of Philadelphia in horse-drawn carriages, collecting bodies from doorsteps.

"One of the most demoralizing things was the inability to move bodies out of the home," said John M. Barry, author of "The Great Influenza," the definitive work on the 1918 pandemic. "They just literally stacked up, sometimes for three, four or five days."

Now, with medical experts and government leaders racing to prepare for a potential pandemic, a cadre of mortuary specialists has begun quietly grappling with the grisly but essential question of what to do with the dead if it happens again.

Opinion is varied on when and how virulent the next global flu outbreak would be, but even a modest epidemic -- similar to the pandemic that hit in 1968 -- could kill between 89,000 and 207,000 Americans. If the next virus mimics the far more potent 1918 strain, the U.S. death toll could reach 1.9 million.

"It's almost too big to wrap your arms around," said John Nesler, a specialist in mass fatalities advising the military. If the worst were to occur, Nesler predicted the impact would be akin to "20 nuclear detonations" simultaneously knocking out multiple cities and towns.

In either case, experts foresee an 18-month period of funeral homes being short-staffed, crematories operating round-the-clock, dwindling supplies of caskets and restrictions on group gatherings such as memorial services. Morgues and hospitals would quickly reach capacity. And most of the federal Disaster Mortuary Operational Response Teams (DMORT) would be too busy in their own communities to deploy elsewhere.

"I can't see myself packing my bags to go to another state to help out," said Joyce deJong, a Michigan medical examiner who worked on DMORT teams after the Sept. 11, 2001, attacks and Hurricane Katrina. "I'll be here dealing with an increase in the number of bodies."

Some fear that the Bush administration, in all its detailed planning for pandemic flu, has paid scant attention to fatalities.

"It's the one thing nobody wants to address, because it's ugly. People don't want to think that anyone will die," said John Fitch, senior vice president for advocacy at the National Funeral Directors Association. "We can't put our head in the sand and say response stops at prevention and treatment."

In the 227-page response plan recently released by the White House, the term "medical examiner" appears just once -- and "autopsy" not at all. A single paragraph on page 112 recommends that hospitals, medical examiners and government officials "assess current capacity for refrigeration of deceased persons, discuss mass fatality plans and identify temporary morgue sites" to handle surges.

Officials say much more is happening behind the scenes. In March, the administration helped organize a two-day conference at Fort Monroe in Virginia with medical examiners, funeral directors, public health experts and casket makers. Among the more innovative, albeit jarring, ideas being considered are backyard burials, virtual funerals and storing bodies at ice hockey rinks.

Seattle's King County came up with the ice rink idea when officials realized their mass fatality plan would accommodate no more than 50 deaths, perhaps in a plane crash, said interim health director Dorothy Teeter.

"This is so much bigger," she said. "We project 11,000 potential deaths in six to eight weeks."

Several participants said they will have to consider temporary mass graves because they will not have the staff to keep up, especially if some of their workers or family members contract the flu.

"They would bury the person with all the identification material and carefully keep track of that information," said Ann Norwood, a senior analyst at the Office of Public Health Emergency Preparedness at the Department of Health and Human Services. "After things calm down, we can locate the family, exhume the casket and put it wherever the family ultimately would like the body to rest."

"Virtual funerals" broadcast over closed-circuit television or the Internet would be advised, said Nesler, who ran the Fort Monroe conference. "The very worst thing you can do during an epidemic is have large gatherings of people" such as memorial services, he said. Some families may bury relatives on their own property, said deJong, who is also chairwoman of the mass fatality management committee of the National Association of Medical Examiners.

In a pandemic, one problem would likely trigger several more, Norwood said. Fuel shortages, for instance, would mean added complications transporting bodies and keeping refrigerated trucks cool.

If funeral directors and other mortuary workers are not given anti-viral medication or a vaccine when it becomes available, they will likely stay home, said Robert Fells, external chief operating officer for the International Cemetery and Funeral Association. "Ironically, funeral directors were at the bottom of the list," he said. White House officials said a priority list for medicine and vaccine has not been finalized.

"Noticeably absent from the discussion" at Fort Monroe were representatives of the Department of Homeland Security, even though they will have overall coordinating responsibility in a pandemic, said Fitch. "Right now, there is no single agency or individual responsible for mass fatalities."

However, much of the burden will fall to local communities and the states, Bush administration officials said.

Virginia's chief medical examiner, Marcella Fierro, said local hospitals, funeral homes and health departments must take the lead, but the state is trying to help now by developing software systems for clerical tasks such as keeping track of the dead and contacting next of kin. She is also compiling a list of retired employees who could step in.

One of the many lessons to emerge from Hurricane Katrina is that Americans are not accustomed to seeing unattended bodies on the streets of a major city, said Michael Osterholm, head of the Center for Infectious Disease Research & Policy at the University of Minnesota. He said less-developed countries may be better positioned to deal with huge numbers of flu fatalities.

If the next pandemic strikes with the same ferocity as the 1918 flu, even the most thorough planning will not prepare people for the emotional toll of such widespread death.

"We've forgotten that people do die from infectious diseases, and our process of dying has become very sanitized," said Norwood, who is also a psychiatrist. "For the whole Western world, it's going to be a shock."

© 2006 The Washington Post Company