U.S. Coroners, Medical Examiners Neglected in WMD Response Planning

By Joe Fiorill
Global Security Newswire

WASHINGTON — More than two years after al-Qaeda’s assault on the World Trade Center demonstrated the possibility of mass fatalities resulting from terrorist attacks, U.S. coroners and medical examiners say they are being largely overlooked in attack response spending and planning ― a problem they say could greatly exacerbate the impact of an attack.

Although a biological weapons attack, in particular, could present an urgent need to process large numbers of bodies while guarding against the spread of infection, coroners’ and medical examiners’ offices are rarely involved in disaster planning, are often not placed on priority lists for vaccinations and appear to have received next to no funding from the new Department of Homeland Security, according to experts in the field.

Hard numbers on the phenomenon are scarce ― the department offered no response to repeated Global Security Newswire requests for data on federal grants to coroners and medical examiners ― but experts such as Frank DePaolo of the New York City Office of the Chief Medical Examiner agreed that there appears to be a nationwide problem.

“I bet, if you go around the country today, rarely do the coroners and medical examiners get involved in the planning. … As far as I know, the only money that’s come to any medical examiners or coroners on the planning side of this is through the health departments,” said DePaolo, who serves as mass fatality and WMD coordinator in his office.

Faruk Presswalla, New Jersey’s medical examiner at the time of the 2001 attack, cited frequent complaints that DHS grants “never make it to the medical examiner.”

The New York office sprang into action after the World Trade Center attack, creating a special mass fatalities team and training most staff to at least some degree. “We considered it urgent enough to have a team up and running in less than a year,” said Barbara Butcher, the office’s director of investigations.

New York, though, is a rare exception to the worrying state of affairs described by DePaolo and others.

Coroners and medical examiners could become key players in responding to a WMD attack in several ways, including by helping to sniff out an incipient attack. Indeed, Presswalla described how he was able to recognize an anthrax infection in a New Jersey patient during the 2001 anthrax mail attacks because he had seen cases in his native India.

Perhaps more likely to become central in response efforts, though, are coroners’ and medical examiners’ efforts to safely handle and dispose of contaminated remains. Improper handling and disposition of bodies could lead to “devastating” results, said Butcher, but with proper training and equipment, a coroner’s or medical examiner’s office could bring about “a miracle ― you could turn a horrible attack into a small, manageable event.”

“What it all boils down to,” she said, “is public health. Mass fatality disposition is now, to my mind, a new discipline in public health.”

In New York, the 2001 attack led medical examiner staff to a new understanding of what would be involved in responding to a biological or chemical attack. “The World Trade Center taught us that we’re on a new millennium now. … Mass fatality management became a new science. It always existed before, but now it was more of a science,” Butcher said.

Butcher said unprepared medical examiner staff could exacerbate a biological attack primarily in two ways: by inadvertently spreading infection and by staying home because of an unfounded fear of getting infected. In the first case, workers using only ordinary precautions might transmit a viral hemorrhagic fever such as Ebola; in the second case, a medical examiner’s office could find itself with a growing pile of bodies but without the services of workers who do not know, as Butcher said, that “there is nothing to fear if you have the appropriate training and personnel protection.”

“It’s either too much confidence or not enough confidence,” she said, summing up the dual threat.

Traditionally, medical examiners investigate the cause and manner of death, identify bodies and, to a lesser extent, aid in disposition of remains. Remains processed by a medical examiner are subsequently turned over to relatives of the dead; a mass fatality event, though, could quickly overwhelm medical examiners’ resources in processing remains and, more importantly, make it dangerous to return remains to families.

The World Trade Center attack left the New York office with about 20,000 pieces from roughly 3,000 bodies. About half of the 3,000 victims have been identified, but about two-thirds of the 20,000 pieces remain unidentified ― a potentially thorny situation for city officials and, according to Butcher, a cautionary tale about how important a coroner’s or medical examiner’s office could become in a WMD attack.

At the World Trade Center, an ad hoc forensic setup emerged with impressive speed but was characterized by a lack of standard protection against infection for staff and an assembly line for processing that saw remains pass through many hands.

“Picture it if all those remains were contaminated. … Each and every one of those remains would have to be decontaminated prior to being brought into the medical examiner’s office,” Butcher said. Adding to the problem, she said, is that “nobody has yet defined what clean or safe really is.”

New York medical examiner staff have determined that a chemical agent “could be decontaminated” in “rather an arduous process,” Butcher said, but a biological agent such as smallpox would present a completely different set of problems.

“There is no effective decontamination. Smallpox cannot be decontaminated, but we have to look, then, scientifically at the handling and disposition issues,” Butcher said.

The latter are generating “a huge controversy right now,” according to Butcher, with some medical examiners advocating cremation as the only option in a biological event, others advocating double-sealed body bags and ― with appropriate body bags priced at several thousand dollars each and crematoriums few and far between ― seemingly everyone worried about a dearth of resources to implement whatever decision is made.

Yet even in this price-constrained environment, the political element of deciding how to dispose of remains is likely to be predominant.

“If we recommended cremation, which many people at the CDC [U.S. Centers for Disease Control and Prevention] say is the way to go for anthrax, smallpox and the viral hemorrhagic fevers, then what of the families who say, ‘No, it’s against our religious beliefs?’ What cemetery owner would accept smallpox victims?” Butcher asked.

“It’s the classic not-in-my-backyard syndrome,” she said, but “what are we going to do about it?”

Even using an emergency declaration to make cremation mandatory ― theoretically possible in an emergency ― would not solve the problem, said Butcher, because of the small number of crematoriums available and the hours required to cremate even one body.

“There are plans in the back of my mind for some things that we’d have to do, but they’re not pleasant,” Butcher said.

Said Presswalla, who has handled smallpox outbreaks in cremation-friendly India, “The ideal would be a mass cremation, but in [the United States], where that would be looked at as an anathema, that would be a political decision. … I don’t think that individual burials, as is the normal standard, should be the procedure to be used, because then, bodies are being transported to different places. You are in great danger of having contamination.”

In Virginia, where a state-level Office of the Chief Medical Examiner dealt with the aftermath of the Pentagon attack on Sept. 11, 2001, a decision about how to dispose of remains in a biological attack would be “based on the facts at the time,” according to Rochelle Altholz, state administrator in the examiner’s office.

“Depending on what the biological agent was, there would need to be a decision made in conjunction with the state health commissioner and maybe even other political figures … as to whether people would need to be cremated or would there be a mass burial,” Altholz said.

Altholz said the state has made no specific decisions, such as the identification of burial locations, on how to handle such an event. “It would need to be a political decision higher than us,” she said.

Despite the centrality of their services to WMD response, coroners and medical examiners tend not to train extensively for an attack, to be well-integrated into local emergency response systems or to possess equipment and other resources they would need in an attack.

Butcher said most offices are “just becoming aware” of their importance in terrorism response and must join her office in becoming “proactive.” Meanwhile, even forward-thinking medical examiners find it next to impossible to secure outside funds for attack planning: The New York office has received “zero outside funding” for its post-Sept. 11 efforts, said DePaolo, despite submitting at least four grant applications in the past six months alone to DHS Office for Domestic Preparedness.

“Historically, the medical examiners and coroners have not been considered part of the first response community,” DePaolo said, “and, as a result, it’s very difficult to see funding come our way, because it results in, typically, funding being taken away from what is otherwise recognized as the first response community.”

Unsuccessful in obtaining direct federal funding, the New York office has created a small special operations squad, the core of which is 30 workers with high-level hazardous materials training. The office also tries to provide all its staff with at least some “awareness” training about mass fatality events and has had personnel trained around the country in federal programs. But even in New York, the country’s biggest city and the site of the main attack on Sept. 11, the medical examiner’s office is far from satisfied with the resources that have been accorded it.

“So far, so good ― we’ve got the plans, we’ve got the people, we’ve got the training,” said Butcher.

“The only thing we don’t have right now is the equipment. Budgetary restraints have made it difficult for us to obtain the equipment for those 30 people to work in Level A,” she said, referring to the highest level of contamination in which her team is trained to work.

Under current planning, New York Police Department equipment would be made available to the examiner’s office. Nevertheless, Butcher is seeking about $200,000 to purchase protective equipment for her office.

“My fear,” she said, “is that, should we face another incident of the magnitude of the World Trade Center, there may not be enough equipment for the Police Department and the medical examiner.”

The office has also focused on cooperation with other city agencies and has been integrated into the city’s new mass fatality response plan. Some workers in the medical examiner’s office received smallpox vaccinations after traditional first responders were given the opportunity, and the office has been compiling research from various federal, state and local agencies into a constantly updated list of mass fatality recommendations.

Overall, budget constraints have kept the office from doing everything it would like to do in planning for an attack. If New York has failed to obtain everything it wants, though, it still appears well ahead of most other offices around the country. “We’ve been told that we’re so far ahead of the curve here,” Butcher said.

The Virginia office works with the state Health Department to drill for emergencies, plan and acquire equipment. The medical examiner’s office employs investigators who would track deaths in an attack and oversee identification of remains, and district medical examiners’ offices have special plans and some protective equipment. Staff have been offered precautionary vaccinations and are on the state’s priority list for emergency immunization in an attack ― “But it did require some work to get us on that list,” Altholz said.

“We have enough supplies to get started,” she said, “but there would definitely have to be supplies brought in or acquired quickly if an event happened.” She said her office is “always” seeking more funding ― just now, for example, the office wants to buy a medical examiner response vehicle.

Overall, Altholz said, “We do feel that there needs to be more concentration on death events.” Resources for disaster planning have increased since 2001, she said, but “it’s been a lot more on the whole system.”

“We would love to have more resources. We obviously feel our work is very important to public safety and public health,” Altholz said.

As DePaolo pointed out, though, a lack of resources does not exempt medical examiners from the need to plan, and some important steps require little money.

DePaolo said most coroner’s and medical examiner’s offices are “underfunded, undersupported and have not put in the time to understand what is going to be required” when mass fatalities occur. He said the offices should at least know “what it would take,” however, and can draw on DHS programs such as the Disaster Mortuary Operational Response Teams, which respond to calls for help in disaster areas, and the Center for Domestic Preparedness in Alabama, which provides free WMD training for first responders.

New York medical examiner personnel train regularly at federal sites, but few coroners’ and medical examiners’ offices are represented at the sessions, said Butcher.

“Mostly,” she said, “the traditional first responders are going. … I never saw another medical examiner staff person there from any other part of the country.”

Officials at the Center for Domestic Preparedness and at neighboring Noble Training Center, whose training programs focus on medical workers, indicated there is little if any medical examiner or coroner participation in their training courses.   John Hoyle, program manager at Noble, said he has space, expertise and equipment to train coroners and medical examiners for mass fatalities but that DHS’ Emergency Preparedness and Response Directorate would have to develop the necessary curriculum.

Whatever training or resources a medical examiner’s or coroner’s office may have, though, the most important step in terrorism preparedness is simply to have a plan, sources agreed. Presswalla said having “plans to get the material that we need” is more important than having the material itself. Butcher said offices should develop at least a “template,” and DePaolo said other offices should look to New York for information, which it is “happy to share.”

Meanwhile, there appears to be little national coordination of efforts to educate and train coroners and medical examiners and to secure more funding for their terrorism preparedness. The U.S. Army Soldier and Biological Chemical Command’s Improved Response Program has released a draft document on mass fatality management in WMD events, and the National Mass Fatalities Institute is another oft-cited resource for training and documentation. The institute is fairly small, though, and medical examiners and coroners are only one of many groups it serves.

The National Association of Medical Examiners has published a mass fatality plan for its members, but its president, Michael Bell, appears resigned to the status quo when it comes to medical examiner involvement in terrorism planning.

“The reality,” said Bell, “is how can you prepare for something which really can come in any type of form? … Let’s face it, most medical examiners’ offices don’t get a lot of money. We’re lucky to get what we have, and a lot of times, that’s not enough.”

“Unless you have the funds for [equipment], and to train [for] how to use it, then I’m not sure” it is useful, said Bell.

He added that “you also have to kind of weigh … what kind of agent would be involved. I mean, I’m not about to jeopardize the lives of my people just because everybody’s rushing around to get to ground zero.”

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