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Mass Fatality Management

Paul S. Sledzik and Sharon W. Bryson

OVERVIEW

For a civilization to deserve that name, all of life must be valued, including the absent life of the dead. Mate Reyes1

INTRODUCTION

Although many methods exist to measure the impact of a disaster, the number of dead speaks the loudest. Caring for the sick, injured, and displaced is understandably the most important work of disaster responders. For the public, media, government, and society, however, the number of disaster fatalities reflects the true magnitude of the tragedy. Acknowledging the effort of mass fatality managers is largely focused on the dead; the work is actually done for the living.

The disaster dead must be located, recovered, transported, stored, examined, documented, tested, identified, and returned to families for final disposition.2–4 Each step requires specialists in forensic science and funeral services. The processing of the dead follows legal requirements dictated by the disaster and by the jurisdiction in which the event occurred. For example, scenes of terrorist bombings must be managed and documented at a level that would not be required for every type of disaster because terrorism is considered to be a criminal activity.

The physical processing of the dead encompasses logistical and scientific considerations, such as location and recovery of remains, forensic identification efforts, handling of the dead, and the final disposition of remains. Information about these processes must be provided to family members, the media, and politicians.5 As the primary focus of mass fatality management, victim identification involves the collection of postmortem data from the victims and antemortem information from the next of kin, and comparison of the data to establish identification. The condition of the remains also influences the process of managing the dead. Such taphonomic factors as burning, decomposition, and fragmentation often make recovery difficult and identifica- tion more complex.

In many countries, mass fatality management has received limited attention from the emergency management and disas-

ter response systems. Myths and uncertainty about the disaster dead are found in media reports, disaster response textbooks, and in comments made by public officials. The presence of large numbers of dead exposes fears and creates confusion among responders, leading to ineffective and misguided attempts to manage appropriately mass fatality events. This confusion is compounded by the fact that mass fatality management is not a traditional first responder or emergency management responsi- bility. It does not fall into typical disaster medical preparedness, training, and response models. Until recently, local jurisdictions and governments have largely overlooked funding, research, and planning for mass fatality management, despite scholarship and after-action reports detailing the short- and long-term impli- cations for the psychological, social, and economic impact of thoughtless handling of the dead and their families. In the past decade, however, mass fatality management has become more formalized with best practices documents, research publications, and after-action reports now influencing the management of the disaster dead.

This chapter examines current methods for addressing disas- ter fatality issues and discusses some of the complicating factors encountered during a mass fatality response. Current best prac- tices for managing disaster fatalities will be discussed. This will include exploring the unique nature of questions that mass fatal- ity events raise, and a discussion of how to mitigate the impact of such events on families, communities, cultures, and govern- ments.

STATE OF THE ART

Legal and Social Concerns in Mass Fatality Management

Effective mass fatality management addresses both the legal con- siderations for death and the humanitarian concerns guiding respect for the dead and their families.3 Proper laws and proce- dures for mass fatality management must be in place before a disaster occurs.

Identifying human remains is a primary objective for the medicolegal, public health, or law enforcement agency respon- sible for investigating deaths.6,7 In most cultures, an official

312 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:40:18.

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identification must be done for legal reasons. Family members of the deceased require documentation of the death, usually in the form of a death certificate or similar legal instrument. Cer- tifying death and the issuance of a death certificate allow the next of kin to legally resolve issues of insurance, wills, probate, child guardianship, and remarriage. For a typical nondisaster death, this process is usually straightforward. With large num- bers of dead from a disaster, however, the process is quickly overwhelmed.

When a disaster management authority responds to a mass fatality event by using mass graves or cremations without an attempt to identify the dead, there are complex long-term polit- ical, economic, and religious effects.3,8 If the domestic laws for certifying death are not followed, the next of kin may be unable to secure the proper legal documents to proceed with obtaining life insurance, inheritance, or government support. Jurisdictions may need to petition courts to issue documents concerning the deceased so that legal matters can be resolved.

In mass fatality events, tension may develop between indi- vidual and societal needs with regard to disposition of remains. Families wish to proceed with funerals and other grief rites that may be in conflict with medicolegal requirements for proper identification. If not kept informed about the process, family members and community leaders may begin to question the forensic efforts, particularly the duration of time needed for the identification process. Providing factual and realistic informa- tion on the process allows families to understand the procedures used to manage the dead and reduces frustration with the recov- ery and identification process.9,10

Broader than the legal considerations are the nearly univer- sal humanitarian and moral obligations codified in state and national laws that govern the treatment of the dead, the need to identify decedents, and determining the status of unidentified remains.3 Outside of national- or state-level laws, international guidelines reflect the importance of recovery, identification and burial of remains, and the proper treatment of the deceased’s families.

In 1998, the United Nations Office of High Commissioner on Human Rights issued the Guiding Principles on Internal Dis- placement. The guidelines, although not legally binding, com- prise provisions codified by international human rights and in humanitarian law that focus on persons displaced by disasters. The principles are well regarded and promoted among the United Nations members. Specifically, Principle 16 of the Guidelines states

1) All internally displaced persons have the right to know the fate and whereabouts of missing relatives

2) The authorities concerned shall endeavor to establish the fate and whereabouts of internally displaced persons reported missing, and cooperate with relevant international organiza- tions engaged in this task. They shall inform the next of kin on the progress of the investigation and notify them of any result

3) The authorities concerned shall endeavor to collect and iden- tify the mortal remains of those deceased, prevent their despoliation or mutilation, and facilitate the return of those remains to the next of kin or dispose of them respectfully

In the area of international humanitarian law, the Geneva Conventions and the Law of The Hague have provisions regard- ing the location, identification, and disposition of human

remains resulting from armed conflicts. Although focused on armed conflict, they proscribe dignity in handling the dead (e.g., individual burial instead of mass graves) and the importance of positive identification of remains. These actions are considered fundamental rights by signatories to these conventions.

The international police organization, Interpol, has pub- lished a Disaster Victim Identification (DVI) Guide to support ongoing programs among its 186 member states. In addition to antemortem and postmortem data collection forms, the guide sets forth recommendations for planning and training in DVI. Interpol’s Standing Committee on DVI issues guidelines to mem- ber states for establishing DVI teams composed of forensic spe- cialists and for using the DVI Guide in all mass fatality events. The Interpol DVI Guide also details specific procedures for mass fatality management and the process of victim identification.

In the specific area of aviation accidents, the International Civil Aviation Organization (ICAO) promulgates standards and practices for international aviation operations and sets protocols for accident investigation involving multiple countries. Several ICAO documents address aviation accident victim identifica- tion.11,12 Two important aspects of accident investigation involve understanding the actions of the crew and determining surviv- ability of those onboard the aircraft. Identification and autopsy of passengers’ and crew members’ remains provides data for these determinations. The ICAO Manual of Aircraft Accident Investigation details the need for investigators to work with civil authorities in the legal identification of victims and in certifica- tion of their death.

The Pan American Health Organization (PAHO) provides a model document detailing guiding principles and procedures for states preparing for the management of human remains result- ing from disasters.3 The role of knowledgeable experts, the need for a responsible agency to coordinate efforts, the respectful han- dling of the dead, and the importance of keeping family members and the affected community informed are integral aspects of the model law. Despite such laws and accepted protocols, these tenets of proper treatment of the disaster dead are sometimes not fol- lowed. Mass graves were used following the 2004 Asian tsunami and comments by public officials following Hurricane Katrina in 2005 indicated a lack of scientific knowledge concerning the potential of disease epidemics from dead bodies.13,14

The bodies of those killed in mass disasters pose little risk of harboring diseases that are transmissible to the living. Typ- ically, the myth is promulgated by the media, politicians, and misinformed disaster responders, and plays on unfounded fear of the dead.13 Mass graves or cremations are the usual responses to the perceived problem. Such actions can exacerbate the dis- tress experienced by family members of the deceased and the community because they are unable to grieve in the culturally accepted manner.3,15 Two areas merit consideration: the overall public health risk and the more specific risk to those handling the dead.

For those not physically handling remains, there is little if any risk associated with the dead. Water- and insect-borne diseases such as dysentery, cholera, plague, and typhoid fever cannot be transmitted to the living from the dead. After death, body temperature drops, thus causing nearly all pathogens within the body to die quickly. In addition, most people killed in events such as earthquakes, floods, hurricanes, and disasters related to noncriminal human activity die as a result of traumatic injuries. Very few of such victims harbor infectious diseases that pose risks to the public.3

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:40:18.

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314 ■ PAU L S. SL E D Z I K A N D SH A RO N W. BRYS O N

For those handling remains, there are risks from diseases such as hepatitis B and C, human immunodeficiency virus, tubercu- losis, and other enteric pathogens;16 however, forensic and mor- tuary workers take precautions against these risks during their regular work in medical examiner offices and funeral homes. Standard precautions and hygiene will typically suffice for those required to handle the dead following a disaster. Forensic and mortuary workers involved in body handling and the more inva- sive procedures such as autopsy should use the precautions taken by forensic pathologists in their daily practices.17

The contamination of groundwater due to the leaching of body fluids from mass graves is another common misconception. No reliable evidence of groundwater contaminated by infec- tious diseases from corpses has been documented by public health and landfill researchers.15 The anaerobic soil environ- ment and the time required for any biological fluids passing through the soil to reach the groundwater would kill viable pathogens.

The cause of a disaster may influence the use of specific regu- lations or procedures for managing the dead. Mass fatality events have been categorized into three types based on etiology: crimi- nal, technological, and natural. Although similar activities occur following each of these types – search and recovery, victim iden- tification, and disposition of remains – the event dictates how these actions are implemented, and whether additional proce- dures are used. For example, the response to a criminal event requires collection of evidence for potential legal proceedings. Determining the cause of a technological disaster requires col- lection of evidence so that recommendations to improve safety in the particular technology can be implemented. In “natural” dis- asters, the cause is often known, so collecting evidence is usually not required. Disease-related fatality events may require autopsy and evidence collection to determine the specific pathogen and its source and some events initially thought to be naturally occur- ring may later be determined to have other causes. Most of the evidence collected by morgue personnel for criminal and tech- nological disasters centers around autopsy, physical evidence on the remains, identification of perpetrators (if they are killed in the event), and separation of investigative evidence that may be commingled with the remains.

In criminally related disasters, such as the September 11, 2001 terrorist events in the United States, the terrorist bombings in Bali in 2002, the July 7, 2005 London transit bombings, and the November 2008 Mumbai terrorist attacks collection and docu- mentation of important forensic evidence was necessary, both at the disaster site and from the remains of victims. In these events, determining the identity of victims and the deceased perpetrators was a critical investigative avenue, as was detailing the victims’ cause of death.

Following the 2002 terrorist bombing of a Bali nightclub, the Australian Interpol DVI team responded to support the Bali- nese officials. Once local police secured the scene, techniques were used to document and collect the remains. In this event, the condition of remains helped discern the center of the blast – an important forensic determination. Analysis of the scene indi- cated the bomb was poorly constructed and the blast was not as powerful as it could have been. Although the number of differ- ent nationalities represented among the victims complicated the collection of antemortem information, the DVI team was able to identify all 202 victims in 4 weeks. The importance of using accepted scientific methods for identification was underscored when the DVI team positively identified nine bodies that had

been previously misidentified by family members using visual recognition.18

In a technological disaster, such as an aircraft catastrophe, building collapse, ferry capsizing, or industrial explosion, victims must be identified and the cause of death determined. Identifying the reason for the disaster also requires collection of evidence. Once the cause is determined, investigators often make recom- mendations to enhance worker or passenger health and safety. For example, correlating passenger injuries with seating assign- ments may aid in reconstructing the sequence of events at the time of a plane crash and are useful in evaluating aircraft safety equipment.19–21

Assessing the cause of mortality in disasters and the resultant changes in public health codes and building requirements under- scores the importance of collecting information concerning dis- aster fatalities and the impact of this research on the safety of the community.22–24 Surveillance of suspicious deaths, an often- overlooked responsibility of medical examiners and coroners, can distinguish bioterrorism events from noncriminal disease outbreaks.17

Mass fatality events caused by chemical, biological, and radiological sources pose complications for recovery, handling, processing, and disposition of remains.25,26 To respond effec- tively, the chemical or biological agent must first be identi- fied. Once known, forensic responders can plan for the level of decontamination and the level of personal protective equip- ment needed. The medicolegal authority should work with the appropriate health and environmental agencies to understand the local laws regarding handling and disposition of any con- taminated remains. For certain types of chemical and biological agents, there are considerations regarding burial or cremation of remains. For victims killed by anthrax, smallpox, or viral hem- orrhagic fever, cremation is recommended over burial. For vic- tims of botulinum toxin, plague, and tularemia, experts recom- mend remains not be embalmed to reduce the risk to mortuary workers.26

Radiological contamination can be internal, external, or result from shrapnel from an explosive device. Removing cloth- ing from the deceased can reduce the risk of secondary external contamination by 90% to those recovering and processing them; most of the remaining external radiological contaminants can be removed by washing the deceased. Monitoring radiological exposure to forensic and mortuary workers and coordinating with knowledgeable experts in radiology will also help to reduce risk.25

Deaths from pandemic events, such as those from pandemic influenza, pose challenges because of the wide geographical area affected and long duration of time for the event. Because pan- demic influenza deaths will most likely occur in homes and in hospitals in numbers exceeding the normal capacity of the local death management infrastructure, storage of remains and final disposition will be important considerations.

Mass Fatality Response Agencies

Mass fatality events are infrequent, but when they do occur, the affected community often seeks assistance. Several public and private organizations can provide help, ranging from offering advice to providing personnel and equipment.

Interpol DVI teams – deployable to mass fatality events in the 186 Interpol member countries – comprise experts in forensic identification such as dentists, pathologists, fingerprint analysts,

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and experienced support personnel. In the U.S., the Disaster Mortuary Operational Response Team (DMORT), a division of the U.S. Department of Health and Human Services, provides support in victim identification for the medical examiner or coroner.28 DMORTs are composed of forensic experts, mortu- ary personnel, and support staff. The DMORT program also maintains three mobile morgues staged across the U.S. The Fed- eral Bureau of Investigation’s Disaster Squad makes fingerprint examiners available, and their Evidence Response Team provides expertise and resources for site search and recovery, particularly in mass fatality criminal events and transportation incidents. International, federal, and private DNA laboratories are avail- able for analysis and comparison of DNA samples.

Nongovernmental agencies such as the International Com- mittee for the Red Cross and the PAHO have experts available to assist in planning mass fatality response operations. State and local funeral director or mortuary service associations can also provide assistance. Private companies specializing in disaster response operations have also developed teams to support mass fatality management and victim identification.

Methods of Identifying Disaster Fatalities

In most disasters, positive identification of disaster victims is based on the comparison of unique biological attributes observed in the remains with concurrent evidence of these features detailed in dental and medical records, radiographs, and other reliable documents.6 This method of comparing antemortem records with postmortem findings is routine in daily nondisaster foren- sic casework. Four methods are most commonly used and each method is scientifically validated using verified and accurate antemortem and postmortem documentation.

1) Comparison of dental records (e.g., radiographs and charts) with dental evidence from remains

2) Comparison of fingerprint/footprint records located in reli- able repositories with friction ridge patterns from the palms, fingers, and feet of victims

3) Comparison of medical documentation of highly unique physical characteristics with similar evidence found on the remains. Such evidence includes (but is not limited to) radio- graphs showing healed fractures and other unique skeletal structures, implanted medical devices with serial numbers, tattoos, scars, and birthmarks

4) Comparison of DNA profiles obtained from the remains to DNA samples of the victim (direct comparison) or DNA from specific blood relatives (indirect or family comparison)

The number of victims, the composition of the victim pop- ulation, and the condition of the remains influence the compar- ison of evidence and ultimately the timeliness of identifications. If antemortem records are available, identifications using dental, medical, and fingerprint methods can be done quickly, usually within several days. These “conventional” methods of identifi- cation lead to the most immediate results because they involve on-site comparison of antemortem and postmortem data. The laboratory requirements of DNA analysis require more time than conventional methods, and DNA identifications take longer to complete.

The term “presumptive identification” is often used to refer to the process of using characteristics or items that suggest a vic- tim’s identity, but which are not unique enough to be definitive.

A presumptive identification based on nonunique biological or portable evidence is often used as a step toward confirming an individual’s identity by using some or all of the scientific meth- ods listed previously. Jewelry, clothing, and visual recognition or facial features by next-of-kin are examples of methods used for presumptive identification. Personal effects such as clothing, wallets, and jewelry are portable items and are often displaced by the forces in play during a disaster. Visual recognition of facial features by next of kin has been shown to be inaccurate because of postmortem changes in the remains and the attendant psychological stress placed on family members involved in the process.29,30

Considerations in Mass Fatality Management

Before fatality management activities progress, the medicolegal authority and the primary forensic responders must answer sev- eral important questions.

■ What is the number of fatalities? ■ What is the potential cause of the event? ■ What challenges exist in searching for and recovering the

dead? ■ Is the victim population open or closed (i.e., unknown or

known victims)? ■ What is the condition of the remains (e.g., complete, frag-

mented, burned, dismembered)? ■ What are the availability, types, and accuracy of the ante-

mortem information? ■ Will forensic efforts focus on identifying all victims or all

remains? ■ What is the role (and the limitations) of DNA in the identi-

fication efforts? ■ What are the concerns and expectations of society and the

next of kin for the identification process?

The answers to these questions determine how forensic per- sonnel will conduct their work, the amount of time the iden- tification process will require, and the limitations to identi- fications.2,31,32

Certainly, the number of fatalities plays a role in the time required to complete the identification process, particularly when the figure rises into the thousands. It is, however, the associated factors of taphonomy and antemortem data avail- ability that often have a more profound effect on the process of identification. As an example, consider two disasters each result- ing in 100 fatalities. The first disaster leaves complete bodies with little taphonomic change (i.e., no burning, fragmentation, or decomposition) and antemortem records for the victims are easily obtainable. The second disaster causes fragmentation of remains, with nearly 5,000 fragments representing 100 victims. Little is known about the victims and locating their associated antemortem information is complicated. If the same amount of forensic capability is provided to both cases, resolving the sec- ond event will take longer, use more resources, and require more complex fatality management decisions.

Based on the information known about a victim population at the time of the disaster, the group is categorized as either open or closed. In a closed population, data about the number and identity of the victims are easily obtainable. Using a victim’s name or other pertinent information, authorities can contact the next of kin to obtain antemortem information. The most

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common example is an aircraft incident wherein a flight mani- fest (supported by ticket purchasing and security procedures) is the initial source for collection of antemortem information. For example, under U.S. law, passenger names and contact informa- tion are provided to federal authorities within a matter of hours following a crash, and the collection of antemortem information can begin shortly thereafter.

Conversely, an open population defines a victim group in which neither the number of victims nor their names are known. Determining the identity of the deceased is often complicated by the public response to the disaster. Emergency managers and law enforcement agencies are often overwhelmed by massive num- bers of inquiries regarding the missing – a common challenge with an open population disaster. Despite frequently held mis- conceptions, family members take actions to reunite themselves with their missing loved ones, including making phone calls to agencies responsible for tracking missing persons and going to the disaster site.33 Creating an accurate list of victims and their status (i.e., alive, injured, or dead) requires a well-designed pro- cess, managed by the agency responsible for tracking missing persons, to sort those reported missing from those actually miss- ing. Ideally, a designated missing persons or casualty call center receives all such inquiries and develops a comprehensive list of those persons reported as missing. From this list, investigators establish a second list of those actually missing through verifying the status of a missing person, eliminating duplicate reports, clar- ifying misspellings, and other errors. Once a victim is known to be missing, the process of obtaining and examining antemortem data can begin.

The challenges regarding management of missing persons in open population disasters are reflected in the initial reports of the number of fatalities, which usually differ substantially from the final figures. Following the September 11, 2001 U.S. World Trade Center disaster, initial media reports indicated that as many as 10,000 people were dead or missing. Subsequent days saw the number range between 3,958 and 6,453.34 As of November 2005, the total number reported missing due to the disaster was 2,749, of whom 1,594 had been identified.35 Recovery and identifica- tion operations were ongoing as of the end of 2008. Follow- ing the Asian tsunami of 2004, the World Health Organization reported 10,000 dead and within 10 days the number expanded to 153,000.36 The final death toll was nearly 250,000, with an understanding that the true number will never be known.29,37

After the terrorist bombings in London on July 7, 2005, a central- ized casualty call center was established (per previous planning efforts) to manage missing persons calls.5 The center received 42,000 calls within the first hour of operation. This number of missing person calls, for an event that killed 38 and injured over 700, underscores the intense public response following a disaster, and the need for authorities to implement a coordinated missing persons call center system.

The condition of the remains also impacts the methods used for their identification and processing.38 When related ante- mortem records are available, complete bodies can be identified quickly because they encompass all the unique physical charac- teristics needed for identification. In cases involving whole or nearly complete bodies, once the body is identified, the decedent is also identified, that is, the number of bodies equates to the number of victims. Using conventional methods, identifications are completed relatively quickly and at comparatively low cost.

Complexities arise when the bodies of multiple victims are reduced to several hundred or thousand body parts of varying

sizes and anatomical structures. Among the fragmented remains are those containing the unique physical characteristic that will lead to a positive identification, such as a hand with ridge skin or a jaw fragment exhibiting dental work. These parts are usu- ally identified quickly (if antemortem data are available), and confirmation of both the victim’s death and their identification is completed. Most of the fragmented remains, however, will not contain these features. These fragmented parts are examined using DNA analysis, usually resulting in identification of addi- tional remains. These isolated body segments can be reassociated with previously identified fragments from the same individual. This ongoing process of identification presents a source of poten- tial discomfort for the victim’s next of kin. Once they are initially notified of the identification, family members should be asked if they wish to be notified each time a body part is identified, or if they prefer to be notified at the end of the identification process.

In both cases, all reasonable efforts to identify fragmentary remains are made, but there are usually remains that cannot be identified, often referred to as common tissue or group remains. These fragments must be managed carefully; families must be informed of their existence and be involved with their final dis- position.

DNA and Mass Fatality Management

DNA analysis is a powerful tool in disaster victim identification and offers a high degree of statistical confidence in its results. DNA provides the ability to identify pieces of remains having no distinctive biological characteristics and the possibility of being able to identify very small fragments of bone. DNA analysis is a laboratory-based procedure, and as such, takes longer and is more expensive than other methods of identification. The over- all DNA effort should be coordinated by the agency responsi- ble for medicolegal DNA identification during nondisaster peri- ods. Before DNA identification begins, several questions must be asked, the answers to which will influence the application of DNA analysis.32 These include

■ How important is DNA to the identification effort? ■ Will every person or every fragment be identified? ■ What is the minimum fragment size that will be identified? ■ How difficult will it be to identify everyone? ■ How long will the recovery efforts last?

DNA identification requires analysis of postmortem (victim) samples, and the collection and analysis of antemortem samples, called reference samples. Reference samples include personal items of the victim that would contain DNA (direct reference samples), DNA samples from biological relatives (family refer- ence samples), and DNA extracted from remains that have been identified using conventional methods. Direct reference samples include toothbrushes, hairbrushes, personal hygiene items, and medical or pathology samples. Family reference samples are eas- ily obtained by use of buccal swabs or blood samples, and the biological relationship of the family donor to the victim must be recorded. Processing of postmortem and reference samples requires the extraction of DNA. Once extracted, the DNA can then be compared for identification.

Not all samples tested provide DNA for analysis. Limitations in DNA analysis are typically in the extraction phase, where actions such as fire, chemicals, and decomposition can destroy or degrade DNA.39 Very small pieces of bone can yield usable

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DNA for comparison, but often these samples are destroyed in the extraction process. This creates a situation in which a body fragment could be identified, but in accomplishing this process, there are no physical remains to return to the family except the tube containing the extracted DNA.

Mass fatality managers must take care to adjust the expec- tations of family members, politicians, and the media about the use of DNA in the identification process because it is a pow- erful tool that is often misunderstood by nonscientists. Emer- gency managers provided the following figures to the public on a regular basis to control such expectations following the World Trade Center disaster: victim samples received; victim samples analyzed; reference samples analyzed; victims identified; victims identified by DNA only; and remains reassociated with victims.32

Given this information, family members, the public, the media, and politicians could see the progress being made and place it in the larger context of the recovery and identification efforts.

Mass Fatality Operations

Mass fatality operations encompass several diverse activities: location, recovery, documentation, and identification of the dead; determining the final disposition of remains; and inform- ing family members of progress and seeking their input on cer- tain aspects of the process. Three operational locations of activity typically develop: the disaster site, the disaster morgue, and the family assistance center where families of the deceased gather to receive and provide information. An effective response allows for continual information exchange among all three sites.

Mass fatality response teams are multidisciplinary because the nature of their participation involves both scientific analysis and cultural and religious aspects of handling the dead. Vic- tim identification teams usually include forensic pathologists, forensic anthropologists, forensic dentists, fingerprint special- ists, DNA analysts, medicolegal investigators, and forensic man- agers. Funeral directors, clergy, crisis mental health experts, and similarly trained personnel support both the disaster respon- ders and provide comfort and information to victims’ families. The services and information provided to family members, often termed family assistance, are a critical element in a mass fatality response. Because the work of managing the dead is done for the living, the support and information provided to the next of kin must be appropriate and thoughtful.

Search and Recovery In the overall disaster response timeline, search for and recov-

ery of human remains follows the completion of life-saving efforts and other first responder requirements. Once the living and injured are treated and removed from the site, the search and rescue operations shift to search and recovery of the dead. The methods used to process a crime scene are logically applicable to the disaster scene. Appropriate search procedures document the scene, ensure that all areas are searched, and make certain that human remains are recognized and recovered properly.40

Forensic personnel work with first responders to document remains, personal effects, wreckage, evidence, and other perti- nent materials before these are recovered. Photographs, video images, diagrams, and mapping technology (e.g., total station or global positioning systems) are used to document the recovery process and record the location of remains. Once documented, remains are then placed in body bags or other similar appro- priate storage containers, tagged, and identified using a simple

numbering system. They are then transported to a temporary storage location or transfer vehicle. Ultimately, the remains will be brought to the storage location at the disaster morgue.

Many factors influence the search and recovery process: size of the impacted area, number of fatalities, condition of the remains, season, terrain, and weather. For example, searching for complete bodies exhibiting little decomposition found in homes following a hurricane may require a period of time, but the actual documentation and recovery is relatively simple. Conversely, the fragmented and burned remains resulting from a relatively small high-speed aircraft crash caused by a terrorist event must be carefully documented at the scene and then analyzed thoroughly once in the morgue.

Disaster Morgue Selection Selecting the location for processing remains is a critical first

step in management of the dead. The disaster morgue is the site of intense, stressful work, lasting weeks or months and consider- ation for the needs of morgue personnel should be the primary focus in deciding where to locate this facility. Ideally, local author- ities will identify a site before an event occurs. Selecting a disaster morgue site pre-event helps emergency managers understand the importance of fatality management before the arrival of forensic responders.

Health, safety, security, and adequate size are key considera- tions in deciding the location for the disaster morgue. Logistical considerations include adequate heating/ventilation/air condi- tioning, lighting, water supply, electrical capacity, telephone and high-speed Internet access, restrooms, drainage (for capturing biohazard wastes), nonporous floors, and forklift accessibility. Proximity to the disaster scene, adequate floor space, access for and placement of refrigerated trucks for remains storage, and office space for workers and support personnel are additional factors. The movement of remains through the morgue facility and other areas where intensive examination occurs should also be carefully arranged. A security plan should be implemented because the morgue often becomes a focus of attention for fam- ily members and the media.

Disaster morgues have been successfully established in air- craft hangers, unused warehouses, securable private buildings, and medical examiner or coroner offices when space and proce- dures allowed. In the latter circumstance, care is taken to separate the daily casework from disaster casework. Portable tents have also been used in situations where an existing physical facility is unavailable. Active public facilities such as schools or community centers should be avoided because of the psychological impact on the community. Hospitals should also be avoided because of potential confusion between family members of injured disaster patients, nondisaster patients, and fatalities. Although disaster victim identification teams have worked in austere conditions, the preference is for a facility that allows them to conduct their work in an appropriate environment.

Remains should be stored in refrigerated trucks or a facil- ity cooled to a temperature that slows decomposition because this process can destroy certain soft-tissue characteristics useful for identification. Refrigerator trucks or similar storage facili- ties should be designated as “unprocessed” and “processed” to keep remains segregated and organized. Racking systems can be installed in refrigerated trucks or warehouse facilities to maxi- mize storage of both complete bodies and fragmentary remains, which can be bagged and collected in bins. Careful management of remains in storage is essential so that specific body fragments

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Figure 21.1. The DMORT disaster morgue at an aviation accident.

can be retrieved for reexamination or release. Remains may require storage for a long period following postmortem examina- tion, particularly if DNA analysis is being used for identification.

Temporary burial is sometimes used as a method for stor- ing remains awaiting examination. Although this method may slow decomposition, depending on the environmental condi- tions where the graves are located, it does require careful man- agement and additional personnel. Temporary burials should be done individually and information about the location of remains thoroughly documented. Remains should be embalmed only after identification, as the chemicals used can destroy DNA and make reexamination difficult.

In the United States, the DMORT system has assembled Disaster Portable Morgue Units (DPMU) containing supplies

and equipment for operating an incident morgue for large-scale fatality events. Some larger jurisdictions and states have also established portable morgues. DPMUs are transportable to the incident site via truck or aircraft and are supported by a team of trained responders who assemble, restock, and repack the DPMU. Equipment and supplies are stored in specialized cases and a load plan facilitates shipment. Once on site, the DPMU is usually operational in less than 24 hours. Figure 21.1 shows the DPMU established in an aircraft hangar following an aviation incident near Wilkes-Barre, PA in May 2000. Figure 21.2 shows the DPMU organized in an abandoned gymnasium on an active military base following the crash of EgyptAir 990 in October 1999. Note the walled sections denoting the workstations for the various parts of the morgue operation. Figure 21.3 depicts a

Figure 21.2. The DMORT disaster morgue showing forensic workstations.

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Figure 21.3. A schematic of a morgue layout showing work areas and remains storage locations.

schematic of morgue operations, with workstations, refrigerated trucks, and processing areas.

Incident Morgue Operations

Several standard operating guidelines for disaster victim identi- fication and morgue operations are available from the websites of organizations such as DMORT, the National Association of Medical Examiners, the U.S. National Institutes of Justice, Inter- pol, and the PAHO. These guidelines reflect the importance of a standardized process for documentation, analysis, quality assur- ance, and respect for the dead. The particulars of the disaster may require modification of parts of the morgue process, but the procedures remain largely the same.

Before processing of remains begins, the medicolegal author- ity must answer the questions posed previously: Will the focus be on identifying and accounting for all the victims or on the identification of all fragmented human remains? The condition

of the remains, the family expectations, the community con- cerns, the quality and quantity of antemortem information, and the available forensic resources impacting the processing of the deceased must all be considered.

Figure 21.4 demonstrates the typical movement of remains through the incident morgue. Controlling the flow of the deceased into the morgue allows for efficient processing and avoids overwhelming the morgue team with remains for analysis. For example, in an event with 100 whole-body fatalities, forensic examiners may choose to analyze only five bodies at one time. Once brought into the morgue, remains are radiographed in their container (e.g., body bag, pouch, or transfer case). Radiographs allow for evaluation of the container’s contents prior to opening. For complete bodies, radiographs can reveal explosive devices or other hazards, personal effects, forensic evidence, the extent of trauma, and potential commingling with other remains in the same container. For fragmented remains, radiographs reveal potentially identifiable body portions, evidence, personal effects, nonbiological material, and the extent of commingling. Radio- graphs are essential for the next step, known as triage.

Triage is the process of sorting the dead, first to remove any material not related to determining identity, and then to assess their potential for successful identification.41,42 In the first step, four categories of materials are typically separated: per- sonal effects; wreckage or other types of evidence; remains with a potential for identification; and remains with no or little poten- tial for identification. Nonhuman biological materials, such as animal bones, are also removed.

During the second step, each body or body part is assessed using a probative index that classifies remains according to their identification potential or investigative value. Triage personnel assess each body or body part for the number of positive and presumptive identifying features that may lead to dental, finger- print, medical, or DNA identification. Remains usually suitable for identification include dental specimens, large body portions, hands, feet, prosthetic devices, and bone showing healed trauma. Accordingly, remains with the greatest potential for identification

Figure 21.4. Morgue operational plan.

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are analyzed first. Small pieces of skin, fatty tissue, muscle, and similar specimens lacking characteristics usable in the identifi- cation process are often set aside and do not initially enter the morgue processing stream. These specimens can, however, be reexamined if the initial identification process could not account for all victims.

The probative index is incident specific because factors such as availability and accuracy of antemortem information impact identification potential. Triage is typically used in cases of frag- mentary remains, but it can be applied to complete bodies. Triage of whole bodies allows for sorting by the potential for iden- tification, such as the presence of dental work or evidence of surgery.

Following triage, remains are moved to the admitting area where a case file containing postmortem analytical paperwork and other administrative data is created. Remains are also assigned a number corresponding to the case file. A simple numbering system reduces confusion and decreases adminis- trative errors. Remains should be assigned consecutive whole number or a similar unique simple consecutive number. Letters, dashes, and similar characters should be avoided (e.g., 34/A-2, 96–0005A34). The first body or body part entering the morgue flow receives number 1, the second receives number 2, the third number 3, and so on. During the course of the morgue analysis, if additional remains are found commingled with a specimen, then the new body part can be brought to the admitting station and assigned the next consecutive number. Morgue personnel can preserve associated numbering systems assigned at the dis- aster scene if they apply a similar logic and simplicity. Data from the scene that are associated with the remains can be placed in the pertinent case file. After identification and reassociation of fragmented remains, the coroner or medical examiner assigns a unique victim number or case number to the remains comprising that individual.

Various technologies can assist in handling large numbers of remains by reducing numbering errors and increasing qual- ity assurance. Computer-readable barcodes and radiofrequency identification chips have been used to manage remains in disaster morgue operations following the World Trade Center disaster, the Asian tsunami, and Hurricane Katrina.43

Once numbered, the individual remains are photographed, radiographed (for forensic analysis), and then escorted through the postmortem examination stations. Forensic scientists with mass fatality experience staff these stations, which are usually referred to by the discipline conducting the work – dental, pathol- ogy, anthropology, fingerprint, and DNA. Requirements of the investigation dictate whether remains will be examined at each station or just at stations that are relevant to a particular body part. For example, fragments of dental evidence would not be examined at the fingerprint station, but the fingerprint analyst may need to indicate on the postmortem forms that they chose not to analyze the fragment. At each station, information is col- lected according to a protocol created for the specific disaster response.

Forensic odontologists staff the dental station where they examine the maxilla, mandible, and any fragments thereof to document dental structures, fillings, and other unique features.44

Fingerprint experts take prints from fingers, hands, and feet (if necessary) for comparison to existing print records. Forensic anthropologists document anatomical structures to determine sex, age, stature, and other pertinent biological attributes useful in identification, such as bone trauma or unique skeletal char-

acteristics. Forensic pathologists examine remains for evidence of unique features, assess information relative to cause of death, and conduct autopsies if necessary. DNA technicians take sam- ples from soft tissue and bone, which will later be analyzed in the DNA laboratory. Interaction across discipline boundaries is essential for successfully completing the process of postmortem documentation. Once finalized, postmortem data are entered into a data management system for later retrieval during the identification process.

These same forensic specialists are also involved in compar- ison of the postmortem data with the antemortem records – the process of positive identification. Regularly scheduled meet- ings between the medicolegal authority and the forensic experts allow for review of current findings and discussion of identifi- cations. Details of each identification are documented, and the information is presented to the medical examiner or coroner for agreement and authorization. This process usually takes place at the disaster morgue for those identifications done by conven- tional methods. If DNA analysis is used, the identifications may take months to complete and a separate DNA identification team is established to document and validate identifications. Once a victim is identified, the next of kin is notified via the medicole- gal authority’s usual process for death notification. Remains may then be released to the next of kin for final disposition, or remains are maintained at the morgue awaiting reassociation based on the next of kin’s decision.

Collection and Use of Antemortem Data Collecting postmortem data is relatively simple compared

with the collection of antemortem information. The resources and efforts applied to the recovery of remains often result in bod- ies or body parts available for analysis soon after life-safety oper- ations have ceased. The standard procedures used in the disaster morgue lead to the accumulation of postmortem data relatively quickly. Locating, analyzing, and interpreting antemortem data is a more complex process because it involves work outside the morgue, reaching out to medical and dental offices, government agencies, and law enforcement bureaus. The presence and useful- ness of antemortem data are easily affected by the disaster itself and the particulars of the victims impacted.

Locating the sources of the various types of antemortem records usually starts with contacting family members, friends, and the employer of the deceased. These sources can provide contact information for the dentist and physician of the victim, and may know if there are fingerprints on file for the deceased. If necessary, family members with the appropriate genetic rela- tionship to the victim can provide DNA reference samples.

Antemortem data availability is affected by various fac- tors within the victim population. For example, individuals of lower socioeconomic status may never have received dental care and thus will have no antemortem dental records. Antemortem records are also sometimes destroyed in the disaster, such as in the crash of a U.S. military chartered aircraft in Gander, New- foundland in 1985 and following Hurricane Katrina.45,46

Antemortem data consist of three types: 1) medical, dental, and fingerprint records; 2) family interview information; and 3) DNA reference samples. Records, such as dental charts, radio- graphs, medical records, fingerprint cards, and photographs detail the presence of the unique biological characteristics of the victim. Because these types of records contain the most accu- rate and verifiable sources of information, they must be obtained through means that detail their source, that is, dental, medical, or

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government office. The Federal Bureau of Investigation, Interpol, and state law enforcement agencies may hold fingerprint records of a victim if there is a history of military service, federal or state employment, or a criminal record.

Interviews with family members and friends of the victim can provide information to help locate antemortem records, col- lect information required for completion of the death certificate, and determine the legal next-of-kin. A family assistance center or similar facility is often established where specialists in funeral ser- vice and forensic identification can interview the family members by using standard interview forms. Interviewers can also contact family members not present at the center by telephone or email to conduct interviews. Interviewers must be familiar with the antemortem data collection form and understand identification methods. Antemortem interviews are difficult for families, and interviewers should possess the ability to work with those suffer- ing from grief. Answers provided by family members and friends regarding the deceased’s biological and medical data should be considered somewhat inaccurate, and therefore, they should be verified before use in the identification process.47 They may, however, be the only sources of antemortem information, par- ticularly when no medical or dental records exist and when DNA will not be used.

If DNA will be used for identification, collecting direct and family reference samples requires coordination and careful doc- umentation. For chain of custody reasons, the DNA laboratory conducting the analysis should also be involved with the collec- tion of the reference and postmortem samples. Specific sample collection kits improve the reliability of family donor informa- tion; the biological relationship of the donor to the victim must be accurately documented.

The efforts of the missing persons call center and the ante- mortem data collection teams will result in the accumulation of large amounts of information. Data management software is necessary for effective data organization.48 The nature of this large data collection effort results in errors from a vari- ety of sources, and methods to locate and correct errors must be implemented. DNA data management is often handled sepa- rately, due to the unique features of the testing, but the data will be cross-referenced with related antemortem and postmortem information.

The amount of antemortem information, scene documenta- tion data, and DNA-based records generated is often dramatically underestimated. For the World Trade Center DNA identification efforts, approximately 260,000,000 pairwise comparisons were made between the nearly 20,000 remains, 6,800 family reference samples, and 4,200 direct reference samples.49 Although the actual comparison time using computer software took only several hours, creating the data for comparison, ensuring its accuracy, and interpreting the results required many months of work.

Ethical Questions in Mass Fatality Response

The decisions and processes involved in managing and identify- ing the disaster dead create unique ethical and moral questions arising from the interplay of three very different worlds: the remains of the victims, the expectations of family members and society, and the tools and technical limitations of victim identi- fication science. These questions often concern how remains are identified, the extent of resource allocation to conduct identifi- cations, and expectations about what is returned to the family

for final disposition. Specifically, such questions include

■ Should the limited resources available to conduct identifi- cation be used to identify all fragmentary remains or all decedents?

■ Why does the identification process take so long? ■ How large does a specimen need to be for testing? ■ Why is not every specimen analyzed and tested? ■ What if a specimen is consumed entirely in testing and yields

DNA that leads to identification? ■ What should be done with unidentifiable remains? ■ Should remains recovered years after a disaster be processed

for identification? ■ At what point does the identification process end?

Answers to these questions are influenced by the character- istics of the disaster, the desires of the family members (indi- vidually and as a disaster-specific group), cultural and religious beliefs about death and final disposition of remains, societal expectations about what science can provide, and the availabil- ity of appropriate forensic identification tools and techniques.3,32

These questions are not unique to disaster work, as forensic scien- tists involved in human rights investigations have raised similar concerns.50 Additionally, the increased use of DNA testing for disaster victim identification has raised ethical questions about the use of samples for such events.51

As society’s agents for managing the disaster dead, fatality managers and forensic scientists use all applicable techniques and technology in the identification process. The science has limitations, however, and these limitations must be explained to family members and society, as their expectations are often at odds with the scientific capabilities. When families believe that identifications will happen quickly, scientists must readjust the families’ expectations to make them more realistic. This difficult but necessary readjustment helps families understand the reasons behind the answers to the aforementioned questions.9,52

Resolving these ethical quandaries is not often done through public dialogue, given the sensitivities of discussing the horrific details of the event. Informed public discussion is essential, how- ever, to answer these questions appropriately.53,54 Family mem- bers of the disaster dead want and deserve frank yet compas- sionate discourse on these questions. The discussion is difficult, but helps families navigate the complex grief process wrought by a disaster while assuring a community that the dead receive appropriate consideration and care.

Taking Care of Mass Fatality Workers

Despite the fact that they deal with death regularly, the psycholog- ical impact of disaster work on forensic responders should not be underestimated. Disaster forensic work is physically and psycho- logically stressful.55–57 Even with the familiarity of working with human remains, certain events increase stress for most foren- sic responders.58 These include the handling of personal effects, examining the remains of children, the condition of remains (particularly aspects of visual grotesqueness, odor, and tactile features), and exposure to a large number of victims. Identifying or personalizing with the victims increases emotional attachment to the remains, may reduce objectivity, and may increase vulnera- bility to psychological distress. Such stressors can result in normal emotional reactions, such as sadness, disgust, anger, pity, fear,

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and numbness. Physical reactions can include headache, sleep difficulties, intestinal problems, appetite changes, and fatigue.59

The most effective coping strategies involve talking with trusted coworkers, appropriate use of humor, reflecting on the larger purpose of the work, avoiding media coverage of the event (particularly information about the victims), and taking regular time off from the disaster work. Camaraderie and talking with colleagues both during and after the event has been shown to be an important source of positive feelings about a disaster response. Peer-support models, as found in fire/rescue and police agencies, are preferable for forensic responders, because outside mental health professionals typically do not understand the particular stressors of forensic work.57 Despite the stress, forensic respon- ders report that disaster work is a valuable experience, provides a sense of accomplishment, and increases their appreciation of life.55

Assistance to Victims and their Families

Because the work of mass fatality responders is performed mainly to comfort the living, it is important that appropriate support is provided to them. Issues to address include the type of help needed when a mass fatality occurs and identifying the needs of the victims and their families after the immediate emergency passes. Survivors of mass fatality events and family members of those killed often experience an “existential crisis” marked by a profound sense of emptiness and despair.60 Family mem- bers, survivors, and others impacted in the community are likely to exist in a state of psychological shock, uncertain about the whereabouts of loved ones and about the future.61

Responding to the needs of those affected is complex from a logistical perspective, yet simple in determining a successful outcome. The complexities arise from the myriad of state, local, and federal agencies, private groups, and local community non- profit organizations each attempting to provide assistance. The measure of success for those assisting family members is simple: it is determined by how effectively the needs of victims and their families are met and by the compassion demonstrated during the response.

Managing a mass fatality event requires coordination among all participants from each area of the disaster response. Prompt and precise communication about the needs of those impacted is crucial. In the chaos of the moment, however, responders can lose sight of the victim’s real needs. There is a tendency to respond based on a broad generalization of what the disaster response should entail. Clearly, there are guiding general principles that influence responders when assisting victims; however, it is equally as important to stay focused on the individual impacted by the disaster. It is often best to reflect on who the victims are and what their needs may be in order to maintain the proper focus and deliver appropriate services.

Listening to victims and their families describe their needs and expectations can also help guide future responses. The U.S. Task Force on Aviation Disaster Family Assistance, formed by the passage of the Aviation Disaster Family Assistance Act of 1996, articulated a series of recommendations.62 For the first time, family members, representatives from the commercial aviation community, government agencies, and nonprofit organizations attempted to create a more effective approach to meeting the needs of victims and their families following an aviation disaster. The guiding principles of this task force have influenced disaster response in ways reaching beyond aviation disasters.

Family members impacted by a mass fatality event describe an overwhelming sense of loss of control over their world. The loss they experience is often in the context of a larger public tragedy.63 When individuals suffer a loss under such circum- stances, they experience grief.64 Grief is expressed in numerous ways, including physical, psychological, behavioral, and social and spiritual responses and reactions.65 The nature of this larger public tragedy makes the grief process more difficult for vic- tims and their families. An effective mass fatality response must carefully consider these aspects and integrate proper remedies.

The grief experienced in response to a mass fatality event is further complicated by the traumatic nature of the incident. Trauma refers to situations out of the normal range of experience and includes things such as suddenness and lack of anticipation; violence, mutilation and destruction; preventability or random- ness of the event; and the mourners’ personal encounters with death. The individual experiences either a significant threat to personal survival or a shocking confrontation with the death or mutilation of others.66 Traumatic events challenge the many assumptions people have about the world and cause them to feel they no longer control the basic facets of daily existence. An effective and responsible effort to assist victims and their fam- ily members must consider the loss experienced and the grief response in the greater context of a traumatic event.

Corr and Doka observed two main elements in ongoing responses to public tragedy: coping with loss, grief, and trauma and finding ways to adapt to a changed world.67 Janoff-Bulman states, “In the end, it is rebuilding of this trust – the recon- struction of a viable non-threatening assumptive world – that constitutes the core coping task of victims.”68

The path from victimization to regaining a sense of con- trol and trust requires the individual to cope with the traumatic event and the grief resulting from the loss of a loved one. Those responding to a mass fatality must be sensitive to this emotional state and have an understanding of what is needed. A systematic approach to address the physical, psychological, social, and spiri- tual needs of victims and their families is vital. These approaches, which take many forms depending on the disaster, help vic- tims and their family members begin to reestablish a sense of control. When handled properly, such interventions will also help them rebuild the shattered trust caused by the mass fatality event.

Corr notes several ideas responders can use to aid people coping with public tragedies.64

■ Assess the specific nature of the tragedy. Who is in need of help and what types of help are they seeking?

■ Understand the distinct characteristics of the tragedy; each is different.

■ Take stock of the available resources. What contributions and limitations exist in those providing assistance?

■ Prioritize the various aspects of the response. Determine who needs help most urgently, and how and when tasks should be undertaken.

■ Be flexible; needs will change during the event. ■ Offer assistance to the responders, both in the immediate

and the long term.

The lives of victims and their family members impacted by a mass fatality will be forever changed. The goal of any response should be to mitigate further trauma and help the vic- tims reestablish a sense of control. Most individuals, with a little

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assistance, can use their coping skills to adapt to even the most horrific of circumstances.

RECOMMENDATIONS FOR FURTHER RESEARCH

Within the past 2 decades, the methods to manage the disaster dead have evolved from unscientific interventions implemented by emergency management to those involving experienced forensic professionals using well-designed and proven meth- ods. In the U.S., for example, states have used Department of Homeland Security funds to purchase disaster morgues. Sev- eral medical examiner offices now employ full-time mass fatal- ity planning and response staff. In the United Kingdom, the Home Office established a section to manage the overall cross- Government Mass Fatalities Workstream. Interpol maintains a Standing Committee on DVI that oversees their international efforts in mass fatality response. The PAHO published several important documents and papers in the mid-2000s that detail approaches to fatality management.3,4 Forensic scientists have contributed to the literature of mass fatality management by developing new procedures for DNA identification and process- ing of victims.2,26,32

Several areas show promise for future areas of research. The large and complex sets of data developed during a mass fatality response require effective management.48,49 Data management and quality control are critical to the victim identification process and any medicolegal considerations, but such activities are often created ad-hoc, with little knowledge gained from past events. Mass fatality mangers must develop well-designed, effective, and user-friendly procedures for data collection and management applicable across forensic disciplines and useful in any area of the globe affected by a mass fatality event.

More research is needed on understanding the accuracy, rel- evance, and utility of categories of antemortem information. The medical and dental fields generate the antemortem records used for identification, and forensic responders would benefit from working with medical records specialists to understand the nature and utility of this essential information. For example, understanding the frequency of chest radiographs (often used for positive identification) in certain cultural and socioeconomic groups (and knowing how and where these records are stored) would help mass fatality responders to know if and how to look for such records.

Continuing this trend, managers must standardize their pro- cedures for all phases of mass fatality response. Given the inter- national aspects of large-scale mass fatality events, standardiz- ing methodologies for collecting postmortem and antemortem information will benefit all forensic responders. Similar work being conducted in several large-scale missing persons projects by the International Committee for the Red Cross and the U.S. Department of Justice should be of particular interest.69,70 The similarities in data management, forensic procedures, and acqui- sition of antemortem information are striking, yet there has been little interaction between the two fields.

Each death in a disaster affects not only the family of that victim, but also the victim’s community and culture. Effective mass fatality management not only focuses on the dead – the most immediate need – but also on providing information for the living. Mass fatality responders must provide a standard of care for the disaster dead and their families reflecting both the needs of the living and the complexities of managing the dead.

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