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How Bodies Were Buried During History's Worst Epidemics

From the black death to the Spanish flu epidemic to last year's Ebola outbreak, what did people do with all those diseased corpses?

Photo by Jari Lindholm, IFRC

There's a common belief that dead bodies pose a major risk of disease, which leads to a lot of hysteria during major epidemics. This is mostly a myth, studies have found. Even so, mass deaths during plagues have changed burial customs as people scrambled to prevent contamination or just find a place to put all the corpses. How do these pandemics alter the funeral practices in the affected areas during the outbreaks?

I've been thinking a lot about these epidemics lately, and the way they alter the way people perceive death, so I examined three large and well-documented epidemics. One—the West Africa Ebola outbreak—is ongoing; the other two are historical.

Photo via Flickr user Jon Bennett

Black Plague, London, 1348-1350

The residents of medieval London were accustomed to being around the dead. The Christian church was the center of cultural life, and people were buried on church grounds. As Catharine Arnold writes in her book Necropolis: London and Its Dead, "With land at a premium, churchyards were communal spaces at the core of parish life, more like streetmarkets than parks. Laundry fluttered above the graves; chickens and pigs jostled for scraps. Bands of traveling players enacted dramas, and desecration was inevitable, with 'boisterous churls' playing football, dancing, drinking, and fighting on the hallowed ground." Poorer residents did not have an expectation of a dedicated funeral plot, often buried in pits wrapped only in shrouds.

As Arnold notes, the "bond between the living and the dead was very different from today," namely because the dead were kept so close.

The arrival of the black plague in fall 1348 changed all this. Plague isn't directly transmitted from contact with dead bodies, but the presence of fleas or lice that often accompanies those bodies can transmit sicknesses to the living—so keeping dead bodies close to the living helped the disease to spread rapidly. Arnold estimates that between a third and a half of London's residents died during this 18-month epidemic.

There was no way these tens of thousands of new dead bodies would ever fit inside existing burial grounds. According to William Maitland's 1756 work History of London, the Bishop of London bought a property called "No-Man's Land" to bury the victims of the plague. When this filled up, a local landowner purchased an adjacent 13-acre property for the same purpose. Later excavations at these mass graves found that the bodies were stacked five deep. Gone were the communal burial spaces where the living and the dead co-inhabited.

According to Arnold, this led many to reexamine many of their core assumptions: "The Black Death led the devout to question the very nature of existence. Death, once the inevitable conclusion of a good Christian life, now became a terrifying apparition, striking without warning and wiping out an entire generation."

What about the effects of death on such magnitude on everyday life? In his book In the Wake of the Plague, Norman Cantor suggests that "the Black Death accelerated the decline of serfdom and the rise of a prosperous class of peasants, called yeomen, in the 15th century."

Cantor explains that "because of labor shortage, the peasants could press for higher wages and further elimination of servile dues and restrictions. The more entrepreneurial landlords were eventually prepared to give in to peasant demands. The improvement in the living standard of many peasant families is demonstrated by the shift from earthenware to metal cooking pots that archeologists have discovered. The Black Death was good for the surviving women. Among the gentry, dowagers flourished. Among working-class families both in country and town, women in the late 14th and 15th centuries took a prominent role in productivity, giving them more of an air of independence."

Photo by the British Red Cross

Spanish Flu, United States, 1918-1919

The 1918-1919 Spanish flu epidemic was large and recent enough that researchers have used it as a case study to inform decision making in the event of a bioterrorism attack. According to the Department of Health and Human Services, between 30 and 50 million people died worldwide. Approximately one-fifth of the world's population was afflicted, and as many as 675,000 died in the United States alone.

Prior to its arrival in the US, the virus travelled through Europe. According to John Barry's The Great Influenza, the virus likely got its name due to an accident of history: "Spain actually had few cases before May [1918], but the country was neutral during the war. That meant the government did not censor the press, and unlike French, German, and British newspapers—which printed nothing negative, nothing that might hurt morale—Spanish papers were filled with reports of the disease, especially when King Alphonse XIII fell seriously ill."

By October of 1918, major US cities were introducing blanket bans on almost all public gatherings and limiting retail hours in an effort to limit transmissions at the behest of the US Surgeon General. This included a prohibition against funerals, and soon it became increasingly difficult to make burial arrangements in the fashion families were used to. According to a 2000 study by Monica Schoch-Spana in the journal Clinical Infectious Diseases:

At the climax of the Spanish flu pandemic, the numerous and rapid deaths overwhelmed undertakers and gravediggers (many of whom were ill) and exhausted supplies of caskets and burial plots. Corpses remained unburied at home as relatives searched for the virtually unobtainable: a willing mortician, an affordable yet "decent" coffin, and a prepared grave. Some funeral homes and cemeteries were accused of price gouging, and local leaders were accused of not doing enough to help the bereaved. With body disposal interrupted, city and hospital morgues exceeded capacity, in some cases tenfold, prompting a search for auxiliary space. Cities took desperate measures: Philadelphia commissioned coffins from local woodworkers, Buffalo produced its own, and Washington, DC, seized railroad cars with coffins en route to Pittsburgh, where the demand was equally desperate.

Witnessing the breakdown in people's ability to hold dignified burials led to a sense of severe disillusionment, Schoch-Spana explains: "Emergency internment measures such as mass graves and families digging graves themselves undermined the prevailing sense of propriety. Bodies stranded at home and coffins accumulating at cemeteries provided powerful symbols of the country's inability to function normally during the fall of 1918."

While public health researchers and historians maintain an acute interest in this epidemic, the greater public seems to have largely forgotten it. The National Archives even has a special page that informs people that Spanish flu had more casualties than World War I. In his book America's Forgotten Pandemic, Alfred Crosby offered an explanation as to why that might be: "The very nature of the disease and its epidemiological characteristics encouraged forgetfulness in the societies it affected. The disease moved too fast, arrived, flourished and was gone before... many people had time to fully realize just how great was the danger."

Photo by Jari Lindholm, IFRC

Ebola, West Africa, 2014-present

According to the CDC, there are upwards of 10,000 dead due to the ongoing West Africa Ebola epidemic that started last. While the hardest-hit countries are struggling to cope with these dire figures, strictly speaking it's not the amount of dead that has driven them to change how they bury people. Rather, it's the nature of the virus itself that has necessitated rapid changes in funeral rites.

Unlike most ailments—including both the plague and Spanish flu—Ebola is highly contagious via direct human contact after a person's death. Burial customs in West Africa traditionally involve family members washing, touching, and kissing the bodies of dead loved ones, thereby significantly increasing their chances of transmission. How many have been infected in this way? As of last November, the World Health Organization (WHO) estimated that "at least 20 percent of new Ebola infections occur during burials of deceased Ebola patients." Indeed, it is believed that patient zero in this latest outbreak transmitted the virus to others during a burial in Guinea.

The initial response was to employ standard disaster response practices referred to by the WHO as " management of dead bodies." These were developed mainly to deal with large natural disasters that leave many dead at once. What ended up happening is that rescue workers in hazmat gear would come and remove bodies for burial or cremation with little regard for standard burial practices in the region. The shortcomings of this approach became apparent within a few months. The CDC found that in Sierra Leone "safe burial practices, as initially implemented, were not well accepted by communities" which led to lack of trust and cooperation with the authorities.

In response to this, the WHO together with the International Federation of Red Cross and Red Crescent Societies (IFRC) and other NGOs, religious groups, and medical anthropologists came up with an improved protocol for burying dead Ebola victims in October of last year. The new protocol refers to " safe and dignified burials." Per the WHO, "the [new] protocol... includes ways for Ebola burial teams to carry out their work safely while respecting family sensitivities."

Abu Bakar Thorodor Jalloh, the cochair of the burials pillar for the Sierra Leone Red Cross read out to me the instructions that the ten-person burial teams are given:

Upon arrival at the house, the burial team supervisor should introduce himself or herself and other team members. A community leader or counselor should be included in the discussion with the family. We are supposed to express condolences for the family's loss, counsel the family about why special steps need to be taken to protect the family, [and] help them to understand the need for safe medical burial. If they wish, we can also allow a family member to give any object that should be buried with the body. We will inform the family of exactly where the body will be taken, and we always treat the body with respect.

While safe and dignified burials are conducted in a culturally sensitive manner, they are still a very risky activity that can only be done consistently at a large scale by trained staff. All burial team members must wear personal protective equipment (PPE). They then spray the area with a strong 0.5 percent chlorine solution before securely placing the body in a body bag, spraying with chlorine again, and then placing in another body bag.

Cremating an Ebola victim is logistically easier than a safe burial, but it's not a common practice in West Africa. Of the countries hit hardest, only Liberia mandated cremation during the height of the epidemic. Sierra Leone and Guinea have been burying Ebola victims in cemeteries.

Notwithstanding a recent uptick in Sierra Leone, new Ebola transmissions are significantly down from their peak in November. How much the new burial practices had to do with that is hard to quantify since they were part of a broader mobilization. The long-term effect of the epidemic and the international response on these communities will also be hard to predict. At least in Liberia, a desire to return to pre-Ebola customs—and perhaps to enhance cooperation with the authorities—seems to be afoot. The government announced at the end of last year it was discontinuing cremation and opening cemeteries for Ebola victims.

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