Disposal of dead bodies during disasters

The myths surrounding corpses are completely unfounded and border on the ridiculous. These beliefs have developed and become ingrained in the psyches of populations with the passage of time. They normally are caused by distortions of religious norms, by superstition, or by simple observation of a presumed reality. We distinguish between religion and superstition because the first generally refers to a set of formally established doctrines. Superstition, on the other hand, arises from a poor understanding of religious beliefs, a mixture of socio-cultural factors, scientific facts, and, even, science-fiction (see Chapter 4). Anthropologists and other scientists recognize that religious customs, superstitions, and myths have a historical root or are based on empirical observations of actual events. For example, disposal of the dead was a matter of major concern during the infamous "black plague" that ravaged Europe; the plague was a major event and gave rise to the appearance of many of the myths concerning corpses. The following section examines the realities behind the myths about the danger of corpses causing epidemics.

EPIDEMIOLOGICAL RISK OF DEAD BODIES IN AREAS WITH ENDEMIC DISEASES We should be very conscientious by emphasizing that a dead body is the result of an epidemic and not the cause of the epidemic. When a natural disaster happens, deaths occur mainly from trauma as a direct result of the type of disaster. In the management of dead bodies, care should be taken with certain endemic diseases (for example, Vibrio cholerae and Mycobacterium tuberculosis, among others), depending on the type of etiology, when priorities for corpse disposal are considered. Care should also be taken because certain vectors (flies, fleas, rodents, or others) can transmit microorganisms harbored in the corpse (host), such as typhus or plague. At any rate, it is important to note that even in these cases, the presence of dead bodies cannot be considered a significant public health threat. The reason dead bodies pose such a limited health threat is that as the corpse desic-

The reason dead bodies pose such a limited health threat is that as the corpse desiccates, the body temperature drops quickly. Even the most resistant bacteria and virus- es die quickly in an animal that has died recently. This makes it extremely difficult for microorganisms to transfer from dead bodies to vectors, and from vectors to human populations. The only thing we can definitively say about dead bodies in disease endemic areas is that they can be carriers of the etiologic agent, without their being the cause of epidemics. Scientific research has not been able to link the presence of dead bodies as the cause of an epidemic in any of the recent disasters or in situations with a great number of fatalities. Cholera is a concern in endemic areas since V. cholerae can have a devastating effect. The concurrence of the cholera season in endemic regions and a disaster with mass fatalities has been a scenario that has caused major concern for more than one public health officer. Overcrowding, poor sanitation measures, and degraded drinking water systems can exacerbate the spread of the disease almost exponentially.

In Zaire, approximately 12,000 Rwandan refugees died in July 1994 due to an epidemic cholera outbreak. It was later determined that the area where the refugees were located was endemic for this disease. I Popular belief attributed the worsening of the outbreak to the presence of corpses, but it could be demonstrated that other factors, such as overcrowding, poor sanitation measures, and the lack of drinking water, were the primary causes. The presence of dead bodies in this refugee camp proved to be only a cofactor when the tragedy was examined, owing mainly to the fact that those handling the bodies did not observe necessary standards of hygiene, which means they became transmitters of the disease. In a few other cases it was due to the fact that dead bodies contaminated drinking water sources.

It is impossible to determine to what extent the dead bodies were responsible in the appearance of the Zaire outbreak, but it is very clear that the cholera epidemic might have declined dramatically if the authorities and emergency personnel had prioritized sanitation measures, housing, and the issues of water and waste management in the refugee camp. In conclusion, it cannot be said that the Zaire incident could have resulted in fewer deaths if body disposal had been a priority. There are several recommendations for proper management of dead bodies in situations such as that described in Zaire: Strengthen personal hygiene measures both of relief and humanitarian workers and of the community in general; Disinfect bodies with a chlorine-based solution; Monitor transport vehicles; Prevent direct contact between the corpse and family members. Bodies can be delivered to the family members in airtight boxes so that they can be buried

Prevent direct contact between the corpse and family members. Bodies can be delivered to the family members in airtight boxes so that they can be buried rapidly in accordance with the customs of the community; In this and many other situations, avoid exposure of the dead bodies to animals. The best way to avoid this is to bury the body. Public beliefs have also associated salmonellosis with the presence of dead bodies. Salmonella, like V. cholerae, is a very resistant bacterium. Chile has experienced serious problems with salmonellosis, and it is regarded as an endemic area. The country had a salmonellosis epidemic between 1977 and 1986 at a time when statistics showed improvement in systems for drinking water and waste disposal due to better sanitation procedures.2

In general, we can say that conditions of overcrowding and poor sanitation measures are directly related with cholera and salmonellosis. There are no conclusive data to quantify the exact effect that dead bodies might have on the spread of salmonellosis, but it is possible that such a connection does exist. Although some authors have linked the spread of salmonellosis to the presence of dead bodies, the connection is as tenuous as the relationship between illness, corpses, and cholera. Popular belief maintains that dead bodies played an active role in some of the salmonellosis epidemics that affected Chile. At any rate, as with cholera, the bodies are only regarded as a cofactor. When situations in Chile and similar cases are carefully examined, it can be concluded that good sanitation infrastructure does not necessarily indicate good health practices in the general population. This important lesson has been difficult to learn in many communities and has proven to be an important cofactor when the relationship between corpses, sanitation measures, and epidemics is examined.

Both Salmonella and V. cholerae are extremely resistant and tenacious organisms. Cholera and salmonellosis outbreaks are serious events, especially in low-income communities. However, the role that high numbers of dead bodies play when they exist in areas with endemic diseases requires a very critical assessment of whether the following can be verified: The area is endemic for the disease in question. Certain baseline data are needed to judge the level of disease in a given area; The disease can survive in a dead body for a considerable period of time; The confluence of the factors previously referenced, together with the local environment and a third potential event (for example, a disaster), make the presence of dead bodies a greater hazard than in "normal" conditions. No single factor can increase the risk due to the presence of corpses. Furthermore, we know that while bacteria such as Salmonella or V. cholerae are resistant, the majority of these microorganisms do not survive for long after the death of the host.

Other diseases should be taken into account: for example, it has been verified that the human immunodeficiency virus (HI V) can survive for 16 days in a corpse, and at temperatures as low as 20C.3 Tuberculosis should be mentioned because it is highly contagious. It can pose a hazard especially during autopsy or handling of the body when air is exhaled from the respiratory tract.4 Several simple techniques dramatically reduce the risk of contagion from this disease. These include placing a cloth over the mouth of the body when it is being handled to prevent the escape of air,5 and ensuring adequate ventilation in the area chosen as a temporary morgue, especially when there are large numbers of corpses.6 In Table 3.1 we list the principal diseases that should be avoided by those responSible for managing corpses in order to avoid possible contagion: Table 3.1. INFECTIOUS RISK OF HUMAN CORPSES

Bacterial infections

Tuberculosis

Streptococcal infections

Gastrointestinal infections

Meningitis and septicemia

produced by meningococcus

Viral infections

Gastrointestinal infections

Creutzfeldt-Jakob disease ("mad cow"

disease)

Hepatitis B

Hepatitis C

HIV infection

Hemorrhagic fever

SCIENTIFIC BASIS OF THE ABSENCE OF EPIDEMIOLOGICAL RISK IN NON-ENDEMIC AREAS There exists little evidence suggesting that dead bodies constitute a risk in areas that are not endemic for certain diseases.8 When a disaster strikes a community, authorities prioritize their actions to address the most pressing public concerns, that is, attending to the injured, the displaced, and the dead. Little time has been devoted to documenting the fact that dead bodies do not constitute a significant risk of infec- tion during a disaster. At any rate, the evidence obtained from emergency operations and subsequent reconstruction projects would indicate that in the majority of the cases the dead bodies do not pose an appreciable risk for public health in areas where there are no endemic diseases. For a more thorough examination of this subject, we should review the scenarios before and after the occurrence of a disaster.

On 17 August 1999, one of the deadliest earthquakes in Turkey's history struck, resulting in approximately 16,000 deaths and more than 44,()()() injured. The emergency teams that converged on the site dealt with Phase I of the emergency and Phase 2 of treatment. The teams worked for two-week periods to treat injuries, illnesses, and traumas that resulted from the incident. They dealt almost exclusively with surgery, births, trauma cases, and neonatal and post neonatal care. Infectious diseases played a very small or no role in the activities of the medical teams.9 The teams prioritized the search for buried survivors, treatment of the injured, and management and organization of the refugees and injured. Disposal of the dead was of secondary concern during this period.