THE THIN WHITE LINE: the history of a future avian influenza pandemic

Chapter 4: "The End is Near"

No space for the dead

    By the time the Canadian epidemic ended, less than 1 percent of the population died because of flu complications. In addition, the epidemic may have indirectly caused significant additional deaths resulting from power outages, fires that weren’t put out, paramedics who didn’t show up, and so on. In any case, due to the deaths directly caused by Avian Flu, the mortality rate in Canada increased by about 60 percent in 2012, from 220,000 to about 320,000. This cost was made all the more tragic because a disproportionate number of 20- to 40-year-olds caught the flu and died.
    Additionally, mortality only told part of the story. There are currently no reliable estimates, but some public health officials believe that for every two deaths caused by flu complications, another individual survived but now suffers some persistent impairment caused by organ damage: blindness, lethargy, disorientation, lower back pain and, astonishingly, a few tragic cases of encephalitis lethargica, or “sleeping sickness,” which produces a range of symptoms but leaves some victims speechless and motionless, like statues.(66)
    The Pandemic lasted a little longer than three months in Canada, with most affected regions impacted almost simultaneously. In each affected region, the epidemic lasted 8-10 weeks. During this time, the number of fatalities, including those who died from the flu as well as all other causes, was approximately the same as what was typically experienced over about eight months during the pre-Pandemic period.

When a person dies, death must be pronounced and certified, the body must be wrapped in a body bag, it must be transported to and stored at a morgue, and then it must be embalmed and then buried, or cremated. Each step requires legally authorized and/or properly trained personnel and resources such as transportation, cold storage, body bags, fluids and crematoria or burial site.
In Alberta, it is estimated that approximately 17,000 deaths occur annually, or an average of about 1,400 per month. During the Pandemic about 10,000 people died in Alberta from the flu, with deaths concentrated over a two-month period. This represented a 60 percent increase in the total deaths in the province in 2012 and raised monthly mortality from 1,400 to 5,400, an increase of 385 percent, for a period of two months.

Figure 4-3. Total mortality in Canada in 2012. Mortality due to all causes other than complications of the Avian Flu is expressed as a monthly average for comparison.

    Looking further at Alberta, consider that the combined morgue capacity of all Alberta hospitals is less than 150 bodies. Another 50 bodies could be stored in the Medical Examiner’s Office in Edmonton and Calgary. If final disposition of the body by burial or cremation typically takes 2-5 days, then that will be sufficient storage for disposition of about 2,400-6,000 bodies during a two-month period. If we average 2-5 days to 3.5 days, this is about 3,400 bodies.
    Before the Pandemic, the Funeral Service Association of Canada (FSAC) established three containers, each able to set up a complete temporary morgue, at three military bases in Toronto, Edmonton and Halifax. These were designed as temporary morgues during disasters such as an air crash or major flood, but were also considered suitable as adjuncts to temporary hospitals during a major epidemic. At the outset of the Pandemic, however, these containers had been transported to Canada’s densest urban centers——two for the Greater Toronto area with its population of more than 4.5 million, and one for the Greater Montreal area with its population of more than 3.7 million.
    In the end, storage needed to be found for more than 8,800 bodies awaiting final disposition during the first two months of the epidemic in Alberta. As funeral homes and morgue space quickly reached capacity in the first weeks of the epidemic, authorities realized they would need additional space as well as transportation. The funeral homes did not report to the government, and while they would continue to provide supplies such as body bags throughout the Pandemic, they could not produce enough storage and transportation resources on their own. Municipal governments would have to work with funeral homes to generate these resources. It fell to the cities to lay their dead to rest.
    Doing so with dignity appeared an impossible task. Typically, bodies are stored for 1-5 days before final disposition begins. But because of the lack of resources, the dead would have to wait longer than that. The morgues themselves must be cooled at a constant temperature of 4-8°C; even at this temperature, after several days, the body will begin to decompose. Unfortunately, with limited resources available for final disposition, bodies would remain in storage for months before they could be attended.

    In Stonebridge, a mid-sized city near Toronto, city officials reached out to religious leaders for help. “Some religious groups maintain small morgues and other facilities and contributed them to the Pandemic effort,” says Tyler Mackenzie, mayor. “But we had to make a deal. The deceased had to be of the same faith.”
    As mortality increased further, city officials worked with the local RHA to conscript refrigerated tractor/trailer trucks and leave them running around the clock outside of the permanent and temporary hospitals, which created a significant demand for waning supplies of diesel fuel. As 70 percent of deaths due to the flu occurred in the hospitals, locating the trucks there was practical although depressing for the morale of people who saw them there. Each truck could hold up to 30 bodies.
    “We painted the trucks white with large red biohazard symbols on them, first to warn the curious that the truck served as cold storage for flu victims, second to cover up the logos of the companies that provided the trucks,” says Mackenzie. “This was yet another deal we had to make. Some companies were eager to help, but they didn’t want the public to associate the Avian Flu with their brands.”
    As these facilities became used up, cities increasingly turned to arenas and curling rinks to store bodies; depending on the size of the facility, they could hold a significant number of bodies. However, even these got filled up just after the epidemic’s peak.
    “We were desperate,” Mackenzie recalls. He says Stonebridge set its sights on businesses that had refrigerators, but decided against the idea. “The restaurant owners literally begged us not to do it. They said we were already driving them to financial ruin by shutting them down. Now we wanted to store Pandemic victims in their refrigerators. They said this would put them out of business entirely.” They claimed the public would never eat at a restaurant that had once stored human remains in its refrigerators.
    Families of the victims obviously found their prospects for laying loved ones to rest distressing. Their loved ones had, as far as they were concerned, died suddenly, violently. The sense of tragedy was amplified by the fact that many of the victims were healthy adults in the prime of their lives. Until the body was properly buried or cremated, they felt their grieving had no closure. Additionally, several cultures and religions require burial within a certain period of time. For example, the Jews, Muslims and people of the Bahá'í Faith are not embalmed, and must be buried within 24 hours. During the Pandemic, this was simply not possible unless a religious group maintained its own facilities. And because of the bans on public gatherings, funerals, other than small, private family funerals, were not allowed—although, whenever possible, they could perform their own religious and cultural ceremonies.
    Government had not intended on having to resort to mass burials or mass cremations. However, as the epidemic wore on and the casualties continued to mount, many municipalities such as Stonebridge had no choice but to begin collective burials.
    Mass burials are graves in which bodies are buried together, often on top of each other, with no identification of the victims. No mass burials took place in Canada during the Pandemic; but collective burials did. Stonebridge called for volunteers and began digging mass graves——a series of 300-ft.-long, 4.5-ft.-deep trenches. The bodies, still wrapped in body bags, were laid to rest next to each other in the trench. Each body was properly identified for later recovery and proper burial.
    “We had to do it,” says Mackenzie. “We had no choice. We’re not proud of it.”
    As this book is being written, municipalities across Canada are still exhuming bodies for cremation or reburial.