Interview with María Dolores Morcillo, Colombian ICRC doctor

One of the most sensitive issues at the current juncture of COVID-19 has been the management of the bodies of the victims of the pandemic. The images of countless bodies in China, Ecuador, Italy, Spain, Brazil and New York and, above all, the mass grave in the latter city, as well as the bodies cremated on the streets of Guayaquil, have left many breathless. . In Colombia it is known that Bogotá, being the capital and the largest city in the country, can only bury 172 people a day. In the other regions, the situation is dramatic. Municipalities such as Tumaco or Buenaventura, in the Pacific, do not even have morgues with sufficient capacity and in their cemeteries there is no room for one more death. (The coronavirus, the dead and the living: Thoughts from home, day 17)

Beyond the protocols approved by the World Health Organization, the Pan American Health Organization, the Red Crescent, the Red Cross and the International Committee of the Red Cross, great philosophical questions revolve around this topic: why is it important to protect the dignity of the dead? Is it an act of respect towards the deceased himself, towards his loved ones or towards society? Are the dead sacred? What do rituals have to do with the dignity of the dead? Is the treatment of the dead a reflection of humanity in 2020?

Colombian doctor María Dolores Morcillo Méndez, forensic coordinator for Lebanon of the International Committee of the Red Cross, has been promoting the dignified treatment of corpses for several years. As she says, “people in general think that dignified treatment means putting the body in a bag, numbering it, cleaning it and burying it well; but most of the time that is not enough. I would speak more of the dignity of the dead. It is the same as in gender issues: it is not only treating women well, but there is a State policy. The true dignified treatment of a corpse is when the person and the relatives are respected, and for that, regulations and policies are required, and not only a protocol. ”

Do you have information on the results of the autopsy of bodies with COVID-19 that have been carried out?

This is a new and behavioral virus not yet well known. At the beginning it was said that the cause of death was pneumonia and severe lung involvement. Already today we know of concepts where a compromise of the cardiovascular system and an inflammatory response have also been found that cause an alteration in blood clotting. This has been established thanks to medical and laboratory studies, but also to autopsies that have helped to clarify what is the damage to the human body. In the case of COVID-19, as in other entities, pathological findings can contribute to determining medical treatment. (Guayaquil families take up to 20 days to know what happened to their dead)

Is there an overview of how many necropsies have been done and in which countries?

The global figure I do not have. It is highly variable, it also depends on the protocols applied by each country with respect to performing autopsies in these cases. What is known are publications that have been made by medical pathologists in China, Italy or the United States. In any case, the number of autopsies so far is very small in relation to the number of deaths we have observed.

Through these necropsies, could the cure or the vaccine be determined?

Yes. Necropsies are used to obtain information that may be useful to help treat the disease and eventually develop a vaccine.

(In Colombia, since March this year, the Ministry of Health restricted the practice of autopsy for people who die from a probable or confirmed diagnosis of the new coronavirus).

Do you think that what we have seen in this pandemic can treat corpses with dignity in the midst of the tragedy?

Anthropologists, lawyers, philosophers and the scientific community will have their vision, because it is a philosophical discussion. The dignified treatment of corpses has been widely questioned, especially in cases of conflict and other situations of violence and with deceased migrants and the treatment that has been given to these bodies in the Mediterranean. It is a topic that is in the forums, more is being written about it and there are those who think that corpses do have rights. Others will think that only the living have them. But the discussion is already given and that simple fact is already an advance. It is a problem that requires a look beyond the technical and is to question whether the human being, after life, remains human, especially on the subject of memory. For example, if you go to a morgue and the director has the corpses stacked one on top of the other, and one asks: if it were your daughter, would you like to be treated like this? There already the idea changes. That dead person is no longer a living person subject to rights, but he was a person once, he has relatives who remember him. Not only the family, but the communities. So there are rituals in countries like Mexico, where the dead are honored. My question is: why is the state scale not reflected in the same way? Just as gender equality, children’s rights, and mental health have been promoted, it is important that there are at least movements to protect bodies. (The Guayaquil drama: where the dead have no rest due to the coronavirus)

The ICRC has protocols for the protection of corpses. Do you think they actually preserve the dignity of the dead?

The ICRC’s aim is to ensure respect for life, physical and moral integrity, and the dignity of all those affected by armed conflict and other situations of violence. For this, it is a promoter of international humanitarian law and humanitarian principles. These and other regulations include legal provisions for the protection of the corpses and relatives of the deceased, so that they can be recovered, identified, buried, and that their personal objects be returned to their families, among others. Normally there is talk of victims and it is inferred that they are living victims: people who lose basic services of water, shelter, food; wounded and sick. The dead are also victims. The ICRC has produced publications promoting the protection of corpses and dignified treatment.

How has this been in the context of the current pandemic?

The ICRC has prepared a series of guideline recommendations available to the public, with guidance both for the proper management of bodies and for authorities and emergency responders, especially in the event of a massive increase in the number of cases . With this COVID-19, many Latin American countries and the entire world have or have developed body management protocols, some more complete than others, but they already have them. But many times these protocols fall short, because there are not enough personnel, infrastructure or resources and for lack of support from the States to the institutions that are in charge of managing the bodies. That is why efforts are being made to move from protocols to principles and policies so that, at the state level and with international organizations that promote human rights, one can look at the bodies and seek their protection, dignity and respect to a high degree.

Have they been able to monitor compliance with ICRC protocols in the context of this pandemic in the countries?

It is very difficult to have an answer. The ICRC around the world, especially in the countries where it is represented, works with local entities to develop and help implement emergency response plans. It is recommended that governments, in all their fields of action, coordinate to provide an adequate and coordinated response to this humanitarian need. A response where the dignity of the deceased and his relatives is always respected and that all efforts are made to ensure a reliable and timely identification and traceability of the body. The network of the forensic community worldwide is very willing and has developed and accepted the ICRC’s recommendations, as well as those of other organizations. At least in terms of promotion and dissemination, I would say that the answer is positive. Whether or not they are being implemented, perhaps each country may have a different response. What has served many countries is that the pandemic did not occur at the same time worldwide, and that has given some countries time to prepare at least. For example, in Latin America these protocols for COVID-19 began to be created when there were still few cases in each country and surely this will demonstrate that preparing has a positive impact on the response to any emergency. (Government asked to cremate the dead of COVID-19, but are there enough ovens?)

Why, existing those protocols, is there a bad management of the corpses in war, migration or disasters like the current one?

In many of the cases it is because there is no legal medical system or forensic services by the State that protect and give adequate management to those bodies, or when it exists it is weak or with lack of resources or simply overloaded by the number of victims and it is a global problem. For example, when the number of deaths exceeds the capacities of local systems, it is already considered a disaster and there should be an emergency response plan for the care of dead bodies that includes aspects such as creating an alternate morgue, allocating a special place to accumulate the bodies, temporarily bury them while they can be exhumed, identified and delivered to their relatives. What happens in many countries is that they do not have care or response plans that include the proper management of the bodies. They have been rather recent events, such as the tsunami, the 9-11 in New York, the hurricane in New Orleans or even the terrorist attacks, which has meant that only some States have contemplated not only care for the living, but also for the dead; But in many countries these plans do not exist. And the absence of these plans determines, among other things, the unworthy management of the corpses. When one asks why this plan does not exist and why the treatment of the dead is so unworthy, one comes to concepts such as what is death, what is a corpse and why they are not cared for or treated like other people despite that they are dead. One finds in all religions that death and its rituals are very important, both for families and for communities, but when the dead do not have a name, these rituals no longer apply, their backs are turned, they are abandoned corpses, They are unprotected, they receive very unworthy treatment.

Do you think it has to do in part with the taboo and the myth that exists around death?

Sure. This taboo leads to the fact that, despite the fact that there are people who dedicate themselves to treating bodies, as in the case of forensics, in many contexts, medical-legal systems have many deficiencies in resources, infrastructure or training, among others. There are no financial resources allocated to this work. If we go further, it is for lack of public policy that puts the dead in the place they deserve. I understand that in the event of an emergency, care is given to those who are at risk of dying than to those who have already died, but in any case, if a society had a policy to protect the deceased, resources would be more in line with what is required. (They tried to displace a corpse by posing as a “sleeping passenger” in Ecuador)

There are those who consider that the protection of the dignity of the corpse also passes through the right to memory. What do you think of this?

All humanitarian guidelines consider rights such as the right to truth, to justice, to know, to dignity and to memory. With regard to corpses, the main principles would be protection, dignity and respect. For example, that a corpse has a name, because identity is part of the respect and dignity of that body. Most of the corpses have relatives, so that this respect also covers the families and there it extends to the right that the relatives have to know, remember and honor their deceased relatives.

Is this right of the relatives to recover the corpse in order to give it a decent burial, a ritual, etc., is it really going to be able to be fulfilled in the framework of this pandemic?

It is difficult to say whether it will happen or not, but the protocols recommend it and call attention to it: that the wishes, interests and rights of family members and communities are recognized and respected. If they cannot be respected because, for example, the practices of some religion generate some risk, then measures can be taken and for that, communication with religious leaders and communities is required to reach agreements. Unfortunately we do not know if all the bodies can be recovered. We have seen in other circumstances, when the number of deaths exceeds the capacities, that it has later been difficult to recover the bodies precisely because there is no proper burial or mapping, so based on experience this happens and it cannot be guaranteed that it will not It is going to happen now, especially in places where there are many bodies. Our intention as forensics and the joint work of the organization and with our interlocutors is to avoid it.

In the case of Colombia, especially in areas affected by the conflict, cemeteries have a special place to bury the bodies of unidentified people. Could those bodies be exhumed in order to bury COVID-19 dead?

In countries where there are laws for handling the bodies of unidentified persons, those bodies are guaranteed to have a place to bury them, and cemetery provisions sometimes do not allow an unidentified corpse to be exhumed to bring in another, except certain special provisions. In that order, bodies of unidentified people are not expected to be removed to bury bodies of COVID-19. Ideally, new spaces suitable for temporary storage or decent storage should be created, and these are also protocol recommendations.

In cases like the one in Tumaco, where the authorities have already warned that they do not have how to handle the bodies, what could happen in a possible case of massive contagion?

It is unfortunate, but these cases occur in many other parts of the world and that is precisely the action on which more attention should be drawn: if an increasing number of corpses is foreseen, you should already think about how to handle them with dignity and bury them according to protocols. There are temporary storage alternatives, either in large spaces, hopefully refrigerated, or in temporary burials. The key is to know that this can happen and if there is no space in the cemetery, at least to know where they can be buried. For this reason, the involvement of decision makers and policy makers is important so that these scenarios are considered and the necessary measures are taken. (With morgues and funeral homes overflowing, New York is looking for where to bury its dead)

In the Middle East, the issue of Islam is fundamental. How has it influenced the management of the corpses of the pandemic?

The ICRC encourages the application of rituals, depending on the cultural and religious origin of the deceased and his relatives. If it cannot be done to avoid contagions, it is important to have adequate communication between health personnel and religious leaders, who are the ones who can authorize that certain procedures that are obligatory in a religion can be avoided or done to a lesser degree. What we have done is, based on information and dialogue with experts on the subject, promote general recommendations in this regard so that dignity and respect can be maintained. We promote that the cultures and religious rites of different cultures are respected and not because a person has COVID-19 and a false belief that the body is going to infect everyone, it goes against the procedures that the community wants . There are cultures, for example, where cremation is not allowed, so that practice should not be an imposition. Care and precautions must be taken when handling the corpses, but unworthy treatment of the corpses would not be justified.

There are several countries in the Middle East with repressive policies. Has this influenced the management of the pandemic figures in any way? Do you think the figures have been hidden?

We handle the figures that each country and that the WHO reports. These reports are based on confirmed tests and we know that many countries do not have the availability to perform them or have limited capacities, so in all countries of the world it is estimated that there are a greater number of infected than those reported, since they do not everyone is being tested and there are asymptomatic carriers.

A major concern that arises with this pandemic is whether the governments of countries in conflict can pass a body victim of the conflict over a corpse of COVID-19. How to distinguish from each other?

This is a situation that can not only happen in an armed conflict between two parties, but also in prisons, in custody deaths or in suspicious deaths where COVID-19 is used in order not to carry out an adequate medical-legal investigation and so hide the true reason for death. In this sense, it is also recommended that COVID-19 is not a reason not to carry out an adequate investigation in accordance with the legal framework. The virus cannot be an excuse for not investigating the deaths to be investigated.