by D Relief · 2004 — of basic services; and, finally, the recovery and management of bodies. recovery of human remains, identification, establishing time of death,
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Also published in Spanish (2004 with the title:Manejo de cad⁄veres en situaciones de desastre (ISBN 92 75 32529 4)PAHO Cataloguing in Publication Pan American Health Organization Management of Dead Bodies in Disaster SituationsWashington, D.C: PAHO, ©2004. 190p, — (Disaster Manuals and Guidelines on Disasters Series, N¼ 5)ISBN 92 75 12529 5 I. Title II. Series 1. DEAD BODY2. NATURALDISASTER 3. DISASTER EMERGENCIES 4. DISASTER EPIDEMIOLOGYLC HC553©Pan American Health Organization, 2004 Apublication of the Area on Emergency Preparedness and Disaster Relief of the Pan American Health Organization (PAHO) in collaboration with the Department Health Action in Crises of the World Health Organization (WHO). The views expressed, the recommendations made, and the terms employed in this publicationdo not necessarily reflect the current criteria or policies of PAHO/WHO or of its Member States.The Pan American Health Organization welcomes requests for permission to reproduce or translate, in part or in full, this publication. Applications and inquiries should be addressed to the Area on Emergency Preparedness and Disaster Relief, Pan American Health Organization, 525 Twenty-third Street, N.W., Washington, D.C. 20037, USA; fax: (202) 775-4578; e-mail: disaster-publications@paho.org. This publication has been made possible through the financial support of the Division ofHumanitarian Assistance, Peace and Security of the Canadian International Development Agency (IHA/CIDA), the Office for Foreign Disaster Assistance of the United States Agency for International Development (OFDA/USAID), the United KingdomÕs Department for International Development (DFID), the Swedish International Development Cooperation Agency (SIDA), and The European CommissionÕs Humanitarian Aid department (ECHO). Cover and interior photos: PAHO/WHO
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iiiForeword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ixPreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiAcknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiiiChapter1. Preparedness formass deaths Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Coordinating institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Preparation of the plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Technical programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Body identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Epidemiologic surveillance and disease control . . . . . . . . . . . . . . . . . . . . . . . .5 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Relations with the community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Relations with the media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Questions commonly asked after a disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Guidelines for the official spokesperson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Proactive approach to media relations for the official spokesperson . . . . . . . .9 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Chapter2. Medicolegal work in majordisasters Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Organization of necessary personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Organization and preparation of the team . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Formation of the group and the warning plan . . . . . . . . . . . . . . . . . . . . . . . . .15 Risk and vulnerability studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Technical preparation of the team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Cooperation agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Exercises and simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Material needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Contents
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MANAGEMENTOF DEAD BODIES IN DISASTER SITUATIONS Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Protective clothing and equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Instruments and equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Body preservation measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Temporary work cams or sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Water and food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Medical care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Disaster professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Other participants in disaster response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Operations coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Search for information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 The place, the event, and the hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Presumed victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Removal of dead bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Procedures at the disaster site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Transfer of human remains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Holding and examination site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Holding area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Viewing area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 Examination area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 Methods foridentifying human remains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44Identification using visual recognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Identification using anthropological studies . . . . . . . . . . . . . . . . . . . . . . . . . .45 Other methods of identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 DNAidentification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Historic background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 DNAidentification process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Accepting cases, managing evidence, and maintainingchain of custody in DNAtyping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Final disposal of corpses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58Low temperatures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 Chemical processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 iv
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CONTENTSvEmbalming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 Burial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66Special bibliography on DNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68Chapter3. Health considerations in cases of mass fatalities Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71Myths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72Epidemiological risk of dead bodies in areas with endemic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73Scientific basis of the absence of epidemiologicalrisk in non-endemic areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76Animal corpses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83Chapter4. Sociocultural aspects Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85The funeral rite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Changes in funeral rites through history . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 Influence of culture, religion, and history on funeral . . . . . . . . . . . . . . . . . . .89 The symbolic value of the corpse and burial . . . . . . . . . . . . . . . . . . . . . . . . . . .95Mourning and rituals in disastersituations . . . . . . . . . . . . . . . . . . . . . . . . . . . .97Unresolved grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98Arguments forthe rapid disposal of corpses . . . . . . . . . . . . . . . . . . . . . . . . . .100Disastermanagement experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106Chapter5. Psychological aspects Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109Specific vulnerabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
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MANAGEMENTOF DEAD BODIES IN DISASTER SITUATIONS The process of unresolved grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Psychiatirc disorders among survivors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116 Notification of disappearance ordeath, and visual recognition of corpses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119 Psychosocial care forsurvivors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121Psychosocial care forfirst response teams . . . . . . . . . . . . . . . . . . . . . . . . . . . .123The importance of truthful, approriate, and timely information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125Role of the authorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128Chapter6. Legal aspects Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129General regulations on managing corpses . . . . . . . . . . . . . . . . . . . . . . . . . . . .129Unidentified bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 Missing persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 Identification of numerous corpses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134Consequences of failure to identify corpses . . . . . . . . . . . . . . . . . . . . . . . . . . .135Provisions of national law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 Provisions of international law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146Model law formanagement of dead bodies in disastersituations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151Chapter7. Case studies The Peruvian experience in managing dead bodies indisastersituations: The Mesa Redonda fire, 2001 . . . . . . . . . . . . . . . . . . . . . .153Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 Actions of the Public ProsecutorÕs Office . . . . . . . . . . . . . . . . . . . . . . . . . . .154 Actions of the Legal Medicine Institute of Peru . . . . . . . . . . . . . . . . . . . . . .155 Activities of the Public Ministry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 vi
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ixOur Region has been the victim of different types of disasters that have had signif- icant, long-term consequences for the development of communities, intensifying the poverty and increasing obstacles to progress, particularly among populations with scarce economic resources.Death does not end human suffering, especially when death is sudden, as the result of a disaster. The death of a loved one leaves an indelible mark on the survivors, and unfortunately, because of the lack of information, the families of the deceased suffer additional harm because of the inadequate way that the bodies of the dead are handled. These secondary injuries are unacceptable, particularly if they are the consequence of direct authorization or action on the part of the authorities or those responsible for humanitarian assistance. Regrettably, we continue to be witness to the use of common graves and mass cre- mations for the rapid disposal of dead bodies owing to the myths and beliefs that corpses pose a high risk for epidemics. The most serious aspect is that these measures are carried out without respecting identification processes or preserving the individu- ality of the deceased. Not only do these actions go against the cultural and religious practices of a population, but they have social, psychological, emotional, economic, and legal repercussions regarding the legacy of the deceased, which exacerbate the damage caused by the disaster. The State has a critical role in standardizing and guiding the tasks of handling deadbodies (recovery, identification, transfer, and final disposal), ensuring that legal norms are followed, and guaranteeing that the dignity of the deceased and their families is respected in accordance with their cultural values and religious beliefs.The Pan American Health Organization (PAHO) is pleased to present this manual, which will be very useful for authorities and those responsible for disaster prevention and response. It is our goal to ensure that the management of massive fatalities forms part of disaster preparedness and response plans, and that it is a fundamental aspect of humanitarian assistance to survivors and rehabilitation and reconstruction programs. In this way we can preserve the memory and dignity of those who have passed before us. Mirta Roses PeriagoDirectorPan American Health Organization FOREWORD
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xiINTRODUCTIONÒWe should treat the dead with respect. In death, money doesn’t matter, material possessions don’t matter; dignity is what we should care about.”Ñ statement byGung Tresna, Lifeguard at Kuta Beach following the terror- ist attack in Bali, Indonesia.Major disasters occurring in this Region, regardless of their origin, have had onething in common: an enormous number of fatalities. Hurricane Mitch in Central America, floods in Venezuela, the earthquake in El Salvador, hurricanes in the Caribbean, and disasters of human originÑsuch as the Mesa Redonda fire in Lima, wars, or aviation accidents, to name a fewÑhave resulted in many deaths. Each dis- aster has yielded important evidence about handling bodies, particularly when the number of dead overwhelms the capacity of a country to effectively respond to an emergency. Immediately following the onset of a disaster, it is essential for national, region- al, or local authorities to concentrate their actions and resources on three basic activ- ities: first, the rescue and treatment of survivors; second, the repair and maintenance of basic services; and, finally, the recovery and management of bodies. Controversy has always surrounded the handling of mass fatalities. Myths abouttreatment of the dead are strongly rooted in culture. Contemplating massive measles vaccination campaigns after an earthquake because of the fear that corpses could transmit this disease, or burying or incinerating corpses without completing required identification processes because of the supposed contamination risk they pose, are just two examples of the myths that form part of the popular culture. Despite efforts by experts to dispel these and other beliefs, certain fallacies have led and continue to lead to unacceptable practices in managing dead bodies. For example, after the earth- quake in India in 2001, in which the number of fatalities approached 100,000, the bodies recovered were cremated. The wood supply was quickly exhausted, leaving the survivors without enough fuel for cooking or heating.1Considering these factors, PAHOÕs Area on Emergency Preparedness and Disaster Relief has developed this manual as a tool to be used by national and local authori- ties and professionals from public institutions that are affected by this issue. This manual provides the technical information that will support the correctapproach to handling dead bodies, taking into account the following principles:uWhen death is the result of a disaster, the body does not pose a risk for infec- tion;uVictims should never be buried in common graves; uMass cremation of bodies should never take place when this goes against the cul-tural and religious norms of the population;1de Ville de Goyet. Ò Stop propagating disaster myths Ó. Lancet2000; 356:762-4.
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