Disasters, armed conflicts, and disease outbreaks often lead to mass fatalities that exceed normal capacities for handling dead bodies. Proper and dignified management of the dead is a vital but often overlooked component of emergency preparedness and response. This article examines the principles, practices, and challenges associated with management of dead bodies following a sudden spike in deaths following catastrophic events. It draws insights from Nepal’s experiences with the 2015 earthquakes and other recent mass fatality incidents globally. The discussion highlights planning and policy shortcomings that compromise the dignity of the dead and prolong the trauma for survivors. It provides recommendations for improving preparedness globally to accord proper respect to the dead amidst dire tragedy.
Understanding Mass Fatality Incidents
A “mass fatality incident” refers to catastrophic events resulting in a high number of fatalities that exceed normal capacities for handling dead bodies. 1 The rapid accumulation and decomposition of bodies pose substantial health hazards from infection and contamination. 1 The lack of adequate refrigerated storage in most low-resource settings leads to an unhygienic accumulation of human remains when existing facilities are overwhelmed. Such situations necessitate extraordinary measures for systematic corpse recovery, storage, and disposal while upholding dignity. Examples of mass fatality incidents include earthquakes, floods, plane crashes, terror attacks, migration tragedies, pandemics, famines, heatwaves, etc.Reference Leoni, Radford and Schulman 2 With climate change and global instability, mass fatality incidents are poised to rise.Reference Leoni, Radford and Schulman 2
Normal Mortality Burdens vs. Mass Fatality Incidents
Even in non-disaster times, the imbalance between resources for handling the living and the dead becomes evident after catastrophic events cause mass fatalities. For instance, managing remains respectfully after an airplane crash requires significant systematic preparedness. But instinct and reflexes turn attention to helping save survivors. However, neglecting proper corpse management has severe public health and emotional consequences, as repeatedly evidenced across mass fatality incidents.
Nepal 2015 Earthquake
Nepal’s mountainous topography and exposure to disasters like earthquake lead to frequent large-scale casualties. The severe tremors in April and May 2015 killed nearly 9000 people and caused widespread damage of infrastructure.Reference Atreya, Kanchan and Menezes 3 Entire villages were buried by landslides, with many bodies remaining entombed under debris. The rough mountainous landscape and enormous scale of the disaster constrained corpse recovery efforts.Reference Atreya, Kanchan and Menezes 3 The absence of temporary cold storage or morgue facilities meant bodies rapidly decomposed when left in the open.Reference Atreya, Kanchan and Menezes 3 Under pressure to dispose of decaying remains, the authorities hastily performed mass cremations without proper identification or adherence to traditional rituals.Reference Fuller 4
Nepal lacked the forensic expertise and logistical capacity to efficiently handle large numbers of dead bodies efficiently.Reference Acharya, Shrestha and Shrestha 5 A poor coordination was evident between various government agencies and departments. No systematic effort was made to collect antemortem data from grieving families to aid in the identification of the deceased.Reference Acharya, Shrestha and Shrestha 5 Lack of refrigeration, unreliable labeling, and haphazard storage of corpses further impeded relatives from tracing their loved ones.Reference Acharya, Shrestha and Shrestha 5 As a result, many could not find closure through customized last rites for their loved ones.Reference Acharya, Shrestha and Shrestha 5 The unmanageable burden and lack of preparedness protocols resulted in extreme indignity in handling the dead.Reference Acharya, Shrestha and Shrestha 5
On-ground Issues in Mass Fatality Response: Accounts from Forensic Experts
A first-hand account of forensic experts who handled the dead after the Nepal earthquake highlights the initial response chaos.Reference Acharya, Shrestha and Shrestha 5 Bodies retrieved were piled in tents and sheds without cold storage as morgues rapidly filled.Reference Acharya, Shrestha and Shrestha 5 The paper-based identification tags soon disintegrated owing to postmortem purging.Reference Acharya, Shrestha and Shrestha 5 In the turmoil, some unidentified dead were wrongly handed to desperate families, falsely claiming them.Reference Acharya, Shrestha and Shrestha 5
Later, the widespread and indiscriminate application of bleaching powder for disinfection led to the release of highly toxic chlorine gas, which injured working staff and damaged remains, further complicating identification efforts.Reference Acharya, Shrestha and Shrestha 5 The absence of standardized procedures and overwhelmed manpower hindered systematic corpse processing.Reference Acharya, Shrestha and Shrestha 5 International disaster victim identification (DVI) teams that arrived to assist did not understand the ground realities.Reference Acharya, Shrestha and Shrestha 5 They narrowly focused on recovering and examining the bodies of their nationality rather than broadly supporting Nepali authorities.Reference Acharya, Shrestha and Shrestha 5
With protocols only on paper and not implemented, the overall response became “like fairy tales” with the dead treated as “gods buried under debris.”Reference Acharya, Shrestha and Shrestha 5 Experts recommended that adequate temporary cold storage capacities must be expanded through mobile morgue units.Reference Acharya, Shrestha and Shrestha 5 Practical techniques like fingerprinting and dental examination can precede DNA analysis for identifying remains in resource-constrained settings.Reference Acharya, Shrestha and Shrestha 5 There is a need for detailed mass fatality response plans and simulations.Reference Acharya, Shrestha and Shrestha 5 Personnel should receive training in systematic DVI procedures while avoiding harmful myths about dead bodies.Reference Acharya, Shrestha and Shrestha 5 Recovery efforts must balance public health concerns with the cultural needs of the bereaved through community participation.
Similar Challenges with Mass Fatalities Globally
Libya 2023 Flood
The September 2023 catastrophic flooding near Libya’s port city of Derna killed an estimated 4000 to 10 000 people when torrential rains caused 2 poorly built dams to fail, unleashing floodwaters through the city.Reference Wintour 6 The aftermath has overwhelmed local authorities, leaving thousands of bodies still unrecovered.Reference Wintour 6 Search and rescue teams continue efforts to locate and retrieve the dead, but many were swept out to sea and may never be found.Reference Wintour 6 With poor record-keeping and political instability plaguing the country, the exact death toll may remain unknown.Reference Wintour 6 The disaster has highlighted major shortcomings in Libya’s infrastructure management as well as its capacity for handling mass fatalities and conducting proper recovery and identification procedures.Reference Wintour 6 Investigations are underway into allegations of negligence related to the long-ignored structural issues with the dams.Reference Wintour 6 The floods show the critical need for improvements in Libya’s systems for dead body management after disasters and other crises resulting in mass fatalities.Reference Wintour 6 The massive scale of the disaster has exceeded the available capacity for individual burials, requiring the undignified mass burial of many unidentified victims once again.Reference Elumami, Al-Warfali and Farge 7
Indian Ocean Tsunami
The Indian Ocean tsunami on December 26, 2004, created immense challenges for authorities in Thailand and other affected countries to properly manage and identify the overwhelming number of casualties, claiming over 200 000 lives across nations.Reference Telford, Cosgrave and Houghton 8 With over 5395 confirmed dead just in Thailand, temporary morgues had to be rapidly established. 9 Refrigerated containers were used to store bodies while disaster victim identification efforts were underway. 9 However, different forensic protocols used by Thai and international teams initially caused delays. 9 Occupational hazards like contamination risks from bodies also existed due to a lack of safety guidelines.Reference Telford, Cosgrave and Houghton 8 By March 2005, approximately 1100 bodies had been identified in Thailand, mainly using dental and fingerprint analysis. 9 But the vast majority of victims were buried without being identified, often in mass graves. 9 The lack of capacity to proper identification and dignified management of bodies on a massive scale meant many tsunami victims’ bodies were not positively identified nor returned to their families. 9 The tsunami exposed the profound difficulties authorities face handling mass fatalities, especially when infrastructure and forensic resources are overwhelmed. 9 The disaster highlighted the need to better prepare nationally and internationally for victim identification and dignified handling of the dead in future catastrophes.
Pakistan Flood
The 2010 floods in Pakistan displaced over 20 million people and was considered one of the worst humanitarian disasters until it was surpassed by the even more devastating 2022 floods affecting over 33 million.Reference Hussain 10 Unlike the 2010 river floods in the north, the 2022 event hit southern provinces Sindh and Balochistan with 500% above average rainfall.Reference Hussain 10 , Reference Khan 11
The 2022 floods caused over 1700 deaths compared to over 2000 in 2010.Reference Hussain 10 , 12 Massive destruction of infrastructure, crops, and livestock has further complicated proper management and burial of the dead.Reference Hussain 10 , Reference Khan 11 As a result of the displacement of millions of people, inadequate coordination, and limited resources, there was a hindrance in the recovery and identification of the deceased in a timely and dignified manner.Reference Hussain 10 As in 2010, the dead bodies piled up and overwhelmed local capacities.Reference Hussain 10 , Reference Khan 11 The lack of cold storage caused rapid decomposition, forcing unceremonious mass burials of unidentified bodies before relatives could locate or recognize their loved ones. Such practices violate cultural values and religious death rituals, causing further psychological trauma to the affected communities.
COVID-19 Pandemic
The COVID-19 pandemic has severely strained mortuary and funeral infrastructure globally, prompting authorities to hastily arrange mass cremations and burials.Reference Petrone, Joseph and Jacquez 13 This limited the participation of families in the last rites. Rising deaths during the severe second wave of the pandemic in 2021 presented serious challenges to dignified and respectful management of the dead.Reference Atreya 14 Due to overcrowding at the cremation grounds, dozens of bodies were cremated simultaneously, disrupting the standard Hindu practice of individual pyres.Reference Atreya 14 In Nepal, some bodies were buried in remote jungle locations by the army without the family’s consent, sparking outrage.Reference Atreya 14 Lockdown restrictions also prevented traditional last rites, with families unable to have a final glimpse of their loved ones.Reference Atreya 14 The lack of resources led to undignified transportation of bodies by bicycle or cart, despite efforts focused on treating the living.Reference Atreya 14 The strains on mortality management and funeral rites during India and Nepal’s COVID surge highlighted the importance of prioritizing capacity, transparency, and compassion when handling mass fatalities to accord both the living and the dead with decency.
Significance of Dignified Handling of the Deceased
The Centers for Disease Control and Prevention has set up recommendations for workers handling dead bodies after disasters, which are mostly cautionary and health-related. 15 However, the deeper significance of dignified handling of the deceased is often overlooked.Reference Giordano 16 Beyond humanitarian considerations, there are several important reasons why according dignity to the dead through systematic corpse management matters:
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# Upholding cultural and religious norms around death rituals and burial practices. Leaving bodies unattended on streets or hastily disposing of them violates the sentiments of affected communities.
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# Providing emotional closure for grief-stricken families. In many cases, after death the body belongs to the relatives or legal heirs. Unidentified bodies and the inability to conduct proper funerals prolong trauma and prevent healing.
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# Mitigating public health risks from rotting corpses that may contaminate water supplies and spread infection if left unattended. Basic precautions are imperative.
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# Enabling legal tasks like processing insurance claims and inheritance distributions which require establishing the identity of the deceased.
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# Allowing forensic analysis to determine accurate causes of death in criminal cases or epidemics. This has social, medical, and legal implications.
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# Facilitating societal reconciliation, justice, and psychological recovery after violent conflict. Respectful burial affirms victims’ dignity and personhood.
Thus, beyond humanitarian considerations, systematic approaches to handling mass fatalities serve practical purposes and uphold the rights of the deceased.
Forensic Human Identification
According to a special report published by the United States Department of Justice, guidelines exist for forensic human identification during mass disasters, intended to assist with victim identification. 1 While the guidelines may seem obvious, proper management of the dead is critical for several reasons. As the report outlines, dignity and respect should be paramount when recovering remains. Bodies should not be left unattended in the open when feasible, for both humanitarian and public health concerns. Proper identification also brings closure to families and allows for important legal procedures like insurance claims. Though basic, adhering to these protocols preserves humanity amidst tragedy. The summary of the guidelines is as follows:
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- Proper management of dead bodies is crucial after a mass fatality event for humanitarian, public health, forensic, and spiritual reasons.
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- Dead bodies should be recovered in a respectful and dignified manner. Remains should not be left in the open if possible.
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- A chain of custody should be established to document the recovery location and movement of remains. Bodies should be labeled with a unique identifier.
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- Refrigerated storage should be made available to preserve remains if burial is delayed.
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- DNA samples should be collected from remains to assist in victim identification. Fingerprints and dental records can also aid identification.
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- Local religious and cultural practices regarding burial should be respected as much as possible. Proper burial provides emotional closure.
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- Public health must be a key consideration, as improper disposal of potentially infectious corpses can spawn dangerous epidemics. Protocols for hygienic, prompt burial or cremation are imperative, while balancing cultural needs.
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- Experts underscore the importance of transparent communication with grieving families during the identification process. An organized information management system can provide closure and comfort to relatives searching for lost loved ones. However, as seen in several recent tragedies, mismanaged record-keeping has prolonged anguish when bodies remain unidentified.
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- International standards on managing the dead should guide response efforts, like those from the World Health Organization (WHO) and the International Committee of the Red Cross (ICRC).
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- Adequate resources and trained personnel are needed for body recovery and mortuary operations. Forensic specialists should assist when possible.
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- Planning and coordination between response agencies is essential for an effective response involving victim identification, storage of remains, burial procedures, and communication with families.
Guiding Principles and Recommended Protocols
The WHO, the ICRC, and individual medical examiners in collaboration with various organizations have provided directives outlining principles and protocols for handling dead bodies after disasters in a respectful and organized manner: 17 – 20
Overarching Principles
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- Treating all deceased individuals with equal respect, regardless of nationality, ethnicity, religion, or social status; no discrimination even in death.
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- Making reasonable efforts to facilitate mourning and customary cultural practices around death to the extent feasible for survivors.Reference Duterme 21
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- Identifying the dead to the extent possible and returning bodies or remains to relatives for final rites and disposal as per community traditions.Reference Duterme 21
Recommended Protocols
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- Providing safe supervised access for grieving families to visually identify bodies of loved ones while avoiding direct physical contact with infectious corpses. 22 , 23
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- Consulting affected families and community leaders on appropriate burial procedures consistent with cultural values and ethos.
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- Implementing basic public health precautions for corpse handlers like protective equipment to minimize infection risks.
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- Avoiding disposal in mass graves or cremations and facilitating individual burials/cremations as per family consent whenever possible.
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- Proper labeling and documentation of unidentified bodies if temporary storage or mass burial cannot be averted due to public health imperatives.
These protocols aim to strike a pragmatic balance between public health concerns, the emotional needs of affected populations, and managing operational challenges. However, they require significant capacity in trained personnel, procedures, infrastructure, and inter-agency coordination. 17 Sadly, such resources are woefully inadequate in much of the world. Guidelines may exist on paper, but actual implementation frequently fails when systems are overwhelmed by disasters, as evidenced by recent catastrophic events.
Recommendations for Improving Preparedness Globally
Disasters are unanticipated and unpreventable events. Aftermath disaster committees and commitments are made which are soon forgotten until the next disaster strikes. Lack of resource and funding from the government sector, lack of training, and lack of preparedness will always result in similar chaotic outcomes.Reference Schultz, Koenig and Schultz 24 A review of a previous catastrophe can help prepare for the anticipated next disaster.Reference Schultz, Koenig and Schultz 24 Disaster-prone countries urgently need to build capacities for handling mass fatality incidents in a systematic and dignified manner.Reference Leoni, Radford and Schulman 2 Preparedness is key as post-disaster improvisation is enormously challenging. Some ways to enhance preparedness include: 20 , Reference Oloruntoba and Sridharan 25
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- Developing detailed contingency plans for possible mass fatality disaster scenarios through simulations and tabletop exercises; setting up protocols, procedures, and infrastructure in advance.
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- Expanding mortuary infrastructure strategically by creating additional capacity and deploying mobile refrigerated storage units to handle mass fatalities.
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- Training personnel, including first responders, health care workers, and volunteers in systematic corpse recovery, storage, transport, and hygienic handling procedures. There are some training modules and guidelines available.Reference Morgan, Tidball-Binz and van Alphen 18 , 26
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- Stockpiling protective equipment like hazmat suits, gloves, and face masks for use by corpse handlers as needed.
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- Identifying temporary burial sites in advance and maintaining body bag reserves for emergencies.
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- Collecting and digitizing antemortem data and DNA samples from communities periodically to aid in the identification of human remains.
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- Augmenting forensic expertise through training programs and international partnerships for rapidly identifying deceased individuals after disasters using DNA, fingerprints, etc.
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- Incorporating dignified, culturally appropriate handling of the dead in national and local disaster management response plans, training, and capacities.
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- Promoting knowledge exchange between international forensic teams and local professionals to strengthen endogenous capacities.
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- Providing vital psychosocial support to grieving families as they cope with catastrophic loss. 27
All at-risk countries should review existing gaps and prioritize enhancing preparedness for systematic corpse management after large-scale calamities. The WHO and humanitarian agencies must encourage and support governments in assessing current deficiencies and building robust response capacities.
A summary table derived from the guidelines and recommendations to serve as a starting point for accessing existing gaps, develop strategies and preparedness for dignified management of mass fatalities is presented in Table 1. It is important to note that the guidelines presented in the table are derived from the reputable sources like WHO and ICRC. These guidelines are generalized and may need to be tailored based upon specific need, available resources, cultural norms, and nature of the mass fatality incident.
Recommendations for dignified management of mass fatalities
Conclusion
Recent large-scale disasters in Nepal and other parts of the world have exposed major deficiencies in capacities for ensuring the dignified management of mass fatalities. With climate change impact intensifying, natural hazards and humanitarian crises will drive more frequent sudden mortality surges globally. Improving preparedness is essential to accord fundamental dignity and respect to the deceased. While saving the living understandably takes priority after any catastrophe, we also have a moral obligation to handle death with empathy. Strengthening capacities for dignified corpse management must be an integral part of emergency preparedness worldwide. Disasters confront us with utter inhumanity, but also present opportunities to reform and reinforce our humanity. With planning, foresight, and compassion, we can bring some closure and comfort even amidst unspeakable tragedies.
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Competing interest
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