Race, education, gender may influence some divergent views about death

Danvers resident John Barbieri looks over a collage of photos of his late wife, Ann “Peachie” Barbieri. They were married for more than 60 years.

By Mark Arsenault and Liz Kowalczyk

A Boston Globe-Suffolk University poll late last year shows that, for the most part, Massachusetts residents share widespread agreement on issues related to the difficult subject of death.

They say society would be better off if end-of-life issues were discussed more openly and believe terminally ill patients should have more options to choose when and how to die. A sizable majority say they would prefer to die at home, and many men and women have first-hand experience with hospice, according to the poll of some 500 residents across the state.

But some major — and subtle — differences emerged along racial, education, and gender lines, a sign that physicians must address cultural attitudes and life experiences, not just medical options, to reduce inequities in end-stage medical care. The poll showed differences in the types of diseases people most dread, how religion affects views on death, and when to stop aggressive treatment at the end of life.

For example, the survey found that Black and Hispanic people are more likely than white and Asian people to say religion and spiritual beliefs guide their medical end-of-life wishes. And it found that Black people more often want to continue treatment for an incurable, debilitating disease than other groups, likely reflecting longstanding fears of under-treatment due to a history of discrimination.

The poll also found women were more likely than men to believe greater public discussion about death is a good thing and have more religious and spiritual beliefs guiding their medical decisions at the end of life. Women were also somewhat more likely to believe in the afterlife.

Differences among groups also emerged on what life-threatening disease they most feared. Black and Hispanic people identified cancer above all, while white and Asian respondents identified Alzheimer’s and dementia as the condition they most dreaded. Similar differences were found along educational lines.

Complete Article HERE!

The Final Chapter

By Melissa Red Hoffman, MD

The first time I saw a death certificate, I was 19 years old. The cause of death was listed as “laceration of the trachea and esophagus, also laceration of heart and lungs with fractures and bleeding caused by two gun shots in the neck and chest.” The death certificate belonged to my father, killed by a terrorist while on a business trip in Cairo. By the time I laid eyes on it, the certificate only served to confirm a very painful truth: My father’s story had come to a very tragic and bloody end.

It’s 26 years later and I’ve managed to use this tragedy to inspire a career focused on both trauma and hospice and palliative medicine. In the simplest terms, I spend half my time trying to save lives and the other half trying to ensure a good death. For me, it works. But there’s no denying that my father’s legacy is always lingering in the background, whether I am in the trauma bay or at a patient’s bedside. The cause of death imprinted on that death certificate, along with the fear, pain and suffering that I assume it caused my dad, and the grief, sadness and never-ending longing that it evoked within me and many members of my family, is never far from my mind. And for reasons that I don’t fully understand, I have reread that death certificate more times than I can count.

That being said, the first time I was actually handed a death certificate to complete, I was well into my yearlong hospice and palliative medicine fellowship, and my only response was, “What am I supposed to do with this?” Despite 10 years of training including medical school, general surgery residency and critical care fellowship, I had never seen this form in the hospital, much less received any guidance on how to complete it. My hospice attending provided some cursory instruction and assured me she was available if I had questions, and that was that.

Since then, I’ve filled out more than 100 of these forms; when I work as a hospice attending, it’s not unusual for me to fill out a half-dozen death certificates during an eight-hour shift. The CDC publishes a free guide ( www.cdc.gov/ nchs/ data/ misc/ hb_me.pdf) that has proven to be helpful to me as I’ve attempted to correctly determine and report the cause of death. State medical boards stress that physicians should exercise their best clinical judgment when filling out the form and that lawsuits involving death certificates are exceedingly rare, but I still sometimes find it nerve-wracking to determine the exact steps that led to a patient’s ultimate demise. While completing a death certificate presents an intellectual challenge and demands a short, but not insignificant, time commitment, I have recently come to view the process as something more profound than another item on my to-do list. Because this form is required for both burial and cremation, I now regard it as both the final chapter of a patient’s life story and the first chapter of a family’s bereavement narrative.

I often think of my father when filling out these forms and it always gives me pause. When I open the medical record, I’m usually touched by the thought that I’m very likely the last physician who will ever study this information. Reading through the chart, I like to linger for a moment or two and think: Who was this patient? What did he do for work? Who did she love, and, just as importantly, who loved her? I also find myself wondering what happened. What, if anything, could we have done differently or better? Could we have caused less suffering? Provided more comfort? Consulted palliative care earlier or at all?

Last week, while I was working at the local inpatient hospice facility, a female patient, five years younger than me and recently diagnosed with metastatic cancer, died before I had the opportunity to round on her. When I went to view her body, I was struck by the stark difference between the glowing, robust woman pictured in a photo hanging above her bed and the bald, gaunt corpse lying curled up on her side. “She truly had nothing left to give,” I commented to the nurse and the chaplain as they gathered her few belongings to return to her family. As I was getting ready to leave for the day, the funeral director arrived to collect her body and asked if I had a few minutes to complete her death certificate. I knew almost nothing about this woman—she had been under my care for only a few short hours—and yet I was tasked, and blessed, with signing off on the final chapter of her life. With this last act of patient care, I was able to support her family in the first steps along their grief journey.

As a surgeon trained in hospice and palliative medicine, my personal narrative has changed from “There’s nothing more I can do” to “Let me walk with you.” Taking the time to complete a death certificate is another way for me, and all surgeons, to follow a patient’s story to the very end.

Complete Article HERE!

Why Indians of all faiths commemorate the dead with food

An excerpt from ‘Turmeric Nation: A Passage Through India’s Tastes’ by Shylashri Shankar.


Each February, on the lunar day my father passed away, I wake up at dawn, bathe and drive over to my mother’s house. I enter the kitchen and begin sorting the vegetables. I wash the spinach and soak it in salted water. The bhindi, I pat dry. I remove the mud clinging to the arbi, rinse the green chillis, ginger and coriander leaves. Then I make a cup of tea for my mother who is unwell, and sit at the dining table to choreograph my cooking moves this year. Sixteen dishes have to be made by half past ten when the priests will arrive. Four hours to wash, chop, chiffonade, boil, cook, simmer, combine, soak, grind and fry vada, knead dough for puris, pickle the mango, roast the arbi over a low flame for half an hour, make the rice, kheer and mango chutney. Everything has to be done from scratch – no preparations can be made the previous day. Even the vegetables have to be cut on the day.

I begin the dance between the tasks like a Sufi dervish, meditatively and fluidly. These were my father’s favourite dishes – keerai, kootu, rasam, puris (we used to compete over how many puris we could eat), bhindi fry, crispy arbi with rice flour and spices, the mango and gur boiled in its own juice, and the mint chutney. These dishes were made on the tenth day after his death, and each year my mother and I make these dishes on his death anniversary. As I cook, I also think of others whom I loved who have passed away – my aunt who lived with us and was famous for her coconut barfis and chikkies, my perima who made the most delicious chutneys, pickles, papads and pastes and sent them to us from Shimoga every couple of months, my favourite uncle who was born on the same day as me and who lived a simple and contented life. I remember the things they did, and what we shared. There is a sense of calm, of peace, of unhurried movement. I salt and spice by instinct, not by taste. I cannot speak over the food, and I cannot taste it – it would be polluting. The priests arrive. After a short chant, they are ready. I serve everything course by course, on a banana leaf. They eat everything and take second helpings. I cook only occasionally, so you’d think the spices would be off, but instinct serves me well on this day. Or is it the emotions and memories infusing the cook?

Research shows that rituals can help in relieving people of their grief and other feelings that torment the spirit. A ritual, whether it is a religious one or something you have made up, helps to restore a sense of control to the mourner, control we have lost in the unexpectedness and the suddenness of the tragedy. A ritual involving cooking returns that control to you as you decide when the coriander seeds have been roasted enough, when the vegetable is done to a crunchy bite, and when the chana is cooked.

It is not surprising that many traditions contain rituals where the person who has passed on is remembered through food. The bereaved are comforted by other mourners who bring dishes like fried chicken, biryani, sandwiches and so on. The Koran, for instance, discourages the family of the dead from cooking but urges the community to bring food to the family. In Hyderabad, Muslims bring biryani, haleem, kebabs and dahi baday. Across the pond in Sri Lanka, visitors dressed in white deliver food to the mourners and the monks. The Buddhist ceremony, Daane, involves eating parupu (dal), kiri bath (rice and coconut milk) and gotu kola sambol. Pitru paksha of Hindus observed during the dark half of the lunar calendar uses food to commemorate the dead. So do similar festivals in other parts of the world: All Souls Day in Italy and Sicily where marzipan delicacies are crafted in the form of fruit and vegetables, and the Day of the Dead in Mexico where sugar skulls, candied pumpkin and mole negro are prepared for the souls of the dead.

Why are these dishes and not some others used in the formal rites? Is it because they create a sense of calm, some succour to the grief-stricken mourners? Is it ethnicity, religion or the geographic location that makes a dish or particular ingredients comforting to a mourner? In India, religion plays a key role in deciding whether vegetarian or non-vegetarian foods can be served to a mourner. Unlike Muslim and Christian mourners, Hindu mourners eat vegetarian meals even if chicken and fish are part of their daily diet. Why? It could be because death is involved in the act of eating meat (dead animals) since in Hindu culture a person is both bodily and morally what he or she eats.

But in a study of mortuary rites in Benares, Jonathan Parry highlights how some aspect of the deceased is symbolically digested not only by the ghost but also by the ‘chief mourner, by the impure Funeral Priests (a specialist subcaste known as Mahabrahmans) and by the pure brahmans’. Parry points out that in some instances, as in the funeral rites of the Raja of Nepal, the Funeral Priest was fed the deceased’s ground-up bone in a preparation of kheer (concentrated milk and sugar), and was laden with gifts and banished from the kingdom. By digesting the deceased, his pure essence is distilled and translated by the digestive fire of the stomach to the other world, while his impure sins are eliminated. The ghost is converted into an ancestor, or pitr. The food served to the group consists of rice boiled without salt but garnished with milk and horse bean lentils (urad dal).On the thirteenth day, the mortuary feast is prepared.

Nirad Chaudhuri narrates an incident where a wealthy relative had to rubber-stamp the backs of peoples’ hands to prevent them from eating twice, many having trekked over 50 miles to attend the feast. It is not just the wealthy who have to feed hundreds of people to mark the end of mourning. The poor have to do it as well, and usually incur high debts as they sell their bullocks and grain and borrow at exorbitant rates of interest to meet the expense of feeding the village. For the Gonds and the Bhumias, the death feast is the most expensive ceremony.

The formal rites also involve other offerings in the soul’s passage from being a ghost to becoming an ancestor. Hindus offer rice or flour balls known as pindas. Some castes leave these pindas outside and hope that a crow will eat it. If it does, the ghost has become an ancestor. In Mysore, some middle castes throw three balls of butter at the idol beseeching it to open the gates of heaven (vaikuntha samaradhana).

Death need not be only of the body. The death of a relationship can be quite brutal. In mourning for the ‘we’ that has died, you may turn to your favourite dishes and binge-eat day after day. Well, don’t. In randomised trials of over 45,000 participants, London-based researchers discovered that eating meals high in vegetable and fiber and cutting back on junk food eased depression. But not anxiety. Also these meals worked better on women than men. They are trying to figure out why. NIH research has found that enhanced recovery from depressive disorders is delivered by oysters, mussels, seafood and organ meats, leafy greens, lettuce, peppers, cauliflower, cabbage, and broccoli. Now we have an Antidepressent Food Score, a nutrient profiling system to give dietary recommendations for mentally ill people.

What about foods that can increase and worsen depression? These typically are sugar-rich foods – cookies, doughnuts, red meats, fried chicken and soft drinks – that create a high followed by a crash. But dark chocolate, thank god, enhances the mood by releasing endorphins to the brain and promotes a sense of well being. I tested it over a two-week period of nibbling two slices of chocolate after lunch. Godiva’s 78 per cent cacao made me perky while Cadbury’s Crunchie left a claggy sensation in my arteries. Either there is some truth to it or I may be exhibiting the recency effect – remembering best whatever I have read or encountered most recently.

The moral of the tale is to treat grief as a natural phenomenon and address it through rituals, simple or elaborate, and eat foods that produce equanimity.

Complete Article HERE!

The Upside Of Virtual Grieving

By Caitlin Stall-Paquet

I attended my first Zoom funeral this past June. My husband Aaron’s aunt Maria, who lived in Pennsylvania, died of breast cancer, but her passing was still defined by the pandemic. Sitting in front of a laptop at the dining-room table in my mom’s house in southeastern Quebec, Canada, we, along with a dozen or so others who couldn’t be there in person, watched our American family gather for the small service.

Despite a few to-be-expected technical issues — people not knowing how to mute or talking over each other — it was incredibly moving. I could see the faces of all the other online participants at once, noticing their collective grief more than I ever would have in person, a mournful mosaic. Towards the end, the funeral organizer asked if anyone joining remotely wanted to share a story. Everyone in attendance turned towards the laptop screen and the grief of the absent unexpectedly took the spotlight. Though I didn’t share, I felt more visible than I ever have attending a funeral, aside from when I delivered my father’s eulogy. It was unlike any service I’ve been to, in a good way.

COVID-19 has forced us to reassess everything in our lives these past few months, but especially our relationship to death and grief. It’s the great force hanging over this pandemic, the thing we fear, what we’re fighting to stave off, while it’s simultaneously thrust in our faces on a daily basis via news reports and press conferences. Though this proximity to loss is a new experience for those who have been luckily shielded from saying goodbye to a loved one, we can all use it to become better at handling grief beyond the pandemic. There have been a lot of calls for not returning to “normal” post-COVID, and the way we mourn deserves to be part of that change.

In part, because many of us aren’t great at dealing with death.When my father died from cancer when I was 29, barely anyone knew how to talk to me about it. (Though it comes from a good place, “I’m sorry for your loss” can start feeling impersonal after a while.) Three-and-a-half years later, I’ve gotten used to my sadness being awkwardly side-stepped or ignored.

There are a few who are willing to dive into the grief weeds with me, who ask questions about my dad and understand that, though the years pass and the pain changes, it never goes away. But many people act like even mentioning someone I love who has died is a faux pas, turning the individuals themselves into taboos. Though grief will always be a personal experience, it doesn’t need to be an isolated one. I’ve never met anyone who wants to be forgotten after they’re gone, so it’s no stretch to assume that the dead want their names in our mouths, shared times in our minds, and swells of feelings in our hearts.

Many of us aren’t great at dealing with death. When my father died from cancer when I was 29, barely anyone knew how to talk to me about it. Though it comes from a good place, ‘I’m sorry for your loss’ can start feeling impersonal after a while.

This loneliness we feelwhen faced with death can be exacerbated by the way we mourn. Although Christianity has been on the decline in the US, our society’s handling of grief has been largely shaped by that faith’s solitary and stoic traditions. For many, grief is seen as something best talked about behind closed doors, and if you’re lucky, in therapy. We’re told to “stay strong” and have been taught to treat mourning as a disease to cure ourselves of within a tidy time frame. After that, we’re mostly silent about our pain rather than reflecting on its shape-shifting, life-altering nature.

This was partially why the Zoom funeral felt so important. It reminded me that, though they’re held to honor the dead, funerals are mostly for the living, one of the few times we’re allowed to mourn openly. The virtual service drove home the importance of coming together even though physical distance felt more impassable than ever. There was also something surprisingly reassuring about attending a funeral at home, surrounded by familiar comforts, with the option of turning off the camera or stepping away from the screen if we needed a moment. It’s unique to be forced to grieve in this new way, so privately and publicly at once. It was something I didn’t realize I’d needed.

For years, I’ve been envious of people who participated in Mexico’s Día de Muertos (Day of the Dead), the holiday that honors those who’ve passed, year after year, long after they’re gone. The celebration reminds me of a trip I took in 2015 to central Bali, just before the one-year anniversary of my uncle John’s death. My visit in the mountains coincided with a Hindu-Balinese cremation ceremony known as ngaben: It started with a long procession through the village for which people wore bright clothes adorned with tons of flowers, and it culminated in an outdoor cremation.

The closest I’ve come to that communal celebration of death was when I was nine years old and my family held a haphazard shiva after my zaida died. As per the Jewish week-long mourning tradition, we covered the mirrors in his Montreal apartment, and people dropped by to sit in uncomfortable chairs. But more importantly, I had a lot of time with my extended family during which zaida’s passing could settle in and move us through a spectrum of emotions, tears, and jokes, solidifying our relationships in the process. That’s the thing about mourning, when it’s shared openly, it brings people together.

Taking the time to let grief sink in feels natural in a pandemic when we’re alone with so much time on our hands.During quarantine, I got more recognition for my sadness than I have in the past, too. Maybe that’s because we were mourning all sorts of things — the normalcy of our lives, our lost connection to each other, the tenuous future. With our everyday fast-paced routines stopped in their tracks, it became painfully obvious how much we craved the contact we’ve taken for granted. Isolation also seemed to make many better at paying attention to what truly matters. On what would have been my father’s 66th birthday, my friend Catherine left me flowers on my doorstep. Another friend left me a voicemail playing one of my father’s favorite songs in its entirety, a gesture that made me laugh-cry like I never had before, and I felt closer to both of them for it.

It’s a cliché that death is the great unifier, but COVID-19 has given us the opportunity as a global population to reflect on what that means and empathize like never before. We can use our times of solitude — as we might have to go back into isolation periodically — to contemplate and appreciate the lives we get to live, while paying our quiet dedication to those who are gone. Allowing the loss to redefine us while also moving on is surprisingly healing, and that in the end is the greatest tribute we can give.

Complete Article HERE!

This ‘Living’ Coffin Uses Mushrooms to Compost Dead Bodies

This ‘Living’ Coffin Uses Mushrooms to Compost Dead Bodies

Hendrikx with the ‘Living Cocoon’ coffins.

by Becky Ferreira

For tens of thousands of years, humans have developed funeral rites and burial practices that reflected the attitudes of their particular time and place. These traditions of honoring the dead continue to evolve into the 21st century, as people seek “green burials” that are more environmentally friendly than standard coffins. 

One of the newest examples comes from Loop, a Dutch biotech company that recently unveiled a biodegradable coffin made of fungus, microbes and plant roots. Called the “Living Cocoon,” the coffin is designed to hasten bodily decomposition while also enriching soil around the plot.

“Normally, what we do as humans is we take something out of nature, we kill it, and we use it,” said Bob Hendrikx, founder of Loop, in a call. “So I thought: what if we humans start moving from working with dead materials toward a world in which we work with living materials?”

“We would not only become less of a parasite, but we could also start exploring super-cool material properties, like living lights, walls that are self-healing, and that kind of stuff,” he added.

Hendrikx was inspired to develop the Living Cocoon while presenting a living home concept at last year’s Dutch Design Week. While houses are obviously for the living, Hendrikx got to thinking about adapting the concept into a coffin powered by mushroom mycelium, which is the filamentary vegetative part of the fungus.

“Mycelium is nature’s biggest recycler,” Hendrikx said. “It is continuously looking for dead organic matter to transform into key nutrients.”

Developed in collaboration with Delft University of Technology and the Naturalis Biodiversity Center, the Living Cocoon contains a moss bed packed with mycelium, plant roots, and a lush ecosystem of microorganisms. It is already on the market in the Netherlands, and has been used for a burial at the Hague.

Initial tests of the coffin indicate that it degrades in soil over about 30 to 45 days, and the Loop team estimates that bodies within coffins should be composted after three years. Mushrooms can also remove contaminants from soil, so the researchers have a “bigger vision” to use the coffins to purify dirty environments.

“We have a dream of having super-new natural funeral-based concepts in which we go to different cities and search for the most dirty soil and start cleaning that up,” Hendrikx said.

“We already have this product launched on the market, but what we want to really know is how long does [decomposition] take exactly, what does the decomposition phase look like, and also—this is super-important—what kind of chemicals can it absorb and in what amounts,” he added.

The Living Cocoon is one of many emerging concepts that aim to reduce the environmental tolls of current mortuary norms. Right now, both caskets and cadavers are treated with chemicals that leach into soil over time, potentially contaminating groundwater.

Green burials are exactly not a new phenomenon, as Indigenous cultures around the world have practiced environmentally friendly mortuary practices for thousands of years. For instance, “sky burials” that expose bodies to high altitudes where they can be scavenged by birds and animals, are still practiced in the Himalayas today.

But more novel funeral technologies such as “water cremation,” in which bodies are broken down in water and potassium hydroxide, are attracting the interest of people who want to tread lightly on the planet, even after they no longer live on it.

To that point, the Loop team thinks that the Living Cocoon will help people access the right end-of-life experience for them.

“I think people are ready for this,” Hendrikx said.

Complete Article HERE!

‘Confirmation of Death’©️

Dr Cathy Welch

The argument about who can or should be responsible for confirmation of death has escalated and evolved over the past few years, alongside changing opinions and legislation regarding CPR and end of life care planning, etc.

But the rise of the Covid-19 crisis has taken the issue to another level. And so, the argument rages on about who owns the rights to use the title ‘Confirmation of Death’©️.

Should death be a medical diagnosis? Are nurses capable of diagnosing death?

And now arise the questions ‘does it have to be a healthcare professional?’; ‘does the healthcare professional have to be there in person?’; and ‘can undertakers confirm death?’

The law has not significantly changed – it still remains that any competent person can confirm death. It‘s only by convention that ‘person’ has been historically replaced (to varying extent by postcode lottery) with ‘healthcare professional’.

Unfortunately, Pulse’s article ‘DHSC says GPs can provide ‘remote clinical support’ for death verification earlier this year continues to use language that perpetuates the unnecessary dogma that this is ultimately a medical role.

Within Dr David Church’s relatively recent blog ‘The stormy night that shaped my views on death verification’, and the following responses, all I see are attempts to justify the status quo based purely on anecdote and modern medical cultural convention. We all want to believe that the days of healthcare policy being based on anecdote are gone, but in reality this is all based on personal bias, hearsay, and myth.

Let’s stop trying to insist that ‘confirmation of death’ is some kind of healthcare copyright issue

So, in the discussions and comments, out come the historical tales of live burials – should we then advocate having a bell system installed in all graves again, as in the 19th Century? And the hypothermic resurrections from the dead – should then every cold body be warmed up, as in the Resus Council hypothermia guidelines (not dead until warm and dead)? Good luck convincing all the hospitals and mortuaries to warm all bodies to normal temperatures before confirming death – they’d be stinking fly pits!

Yes, errors do happen, but extremely rarely. Healthcare-only verification of death is a modern phenomena, driven by persisting attempts to use medical ‘knowledge’ to run away from the inevitable. It’s time to grow up and stop using rare ‘errors’ in verification to cling to current imperfect, unsustainable and inhumane dogmatic ‘rules’ governing ownership of death. How will western society finally grow some cultural wisdom and accept that death is a normal part of life? That death is not failure, not an error, but is an absolute fact of existence, with a 100% lifetime prevalence?

It won’t, as long as the medical/healthcare world continues to grasp at and peddle the concept that death is a medical diagnosis, and can only be confirmed by someone with a five-year degree and however-many years’ apprenticeship. As long as the Grand Guild of Medical Magicians continues to promote the myths that life and death are under our mysterious control, people will continue to live in the shadows of mortal fear, beholden to us to rescue them, and so keep expressing the very same unrealistic expectations that GP mages complain about every day.

My opinion on confirmation of death… the bodies of those who have died will all be dealt with by either an undertaker (mostly), or a pathology morgue. Undertakers are the experts in management of death – handling, dressing, caring for and disposing of the bodies of the deceased. Surely then, they are best placed to be trained in recognition and confirmation of death in the community, as a standard part of their normal procedures?

Death is not a medical ‘condition’ or ‘diagnosis’ to warrant its control by medical/healthcare workers, any more than birth or taxes. Hand back normality to the people. Then, we may find other unrealistic expectations ‘imposed’ on us from our patients start to dissolve away too, because we‘ve been the ones clinging to their ‘need’ for us all the time.

Let’s stop trying to insist that ‘confirmation of death’ is some kind of healthcare copyright issue.

Complete Article HERE!

Medieval pandemics spawned fears of the undead, burials reveal

A 16th-century drawing by Hand Baldung Grien depicts a German mercenary speaking with Death. As pandemics swept Europe, stories of hungry and vengeful undead grew in German-speaking lands and may be reflected in burial practices.

By Andrew Curry

In 2014, Swiss anthropologist Amelie Alterauge was just a few days into her new job at Bern University’s Institute of Forensic Medicine in Switzerland when she was called to investigate an odd burial in a centuries-old cemetery that was being excavated ahead of a construction project. Of some 340 burials in the cemetery, one stood out: a middle-aged man, interred face-down in a neglected corner of the churchyard. “I had never seen such a burial in real life before,” says Alterauge.

Excavators found an iron knife and purse full of coins in the crook of his arm, positioned as though they had once been concealed under his clothes. The coins helped archaeologists date the body to between 1630 and 1650, around the time a series of plagues swept through that region of Switzerland. “It was like the family or the undertaker didn’t want to search the body,” Alterauge says. “Maybe he was already badly decomposed when he was buried—or maybe he had an infectious disease and nobody wanted to get too close.”

The discovery set Alterauge off on a search for more examples of face-down, or prone, burials in Switzerland, Germany, and Austria. Though extremely rare, such burials have been documented elsewhere—particularly in Slavic areas of Eastern Europe. They are often compared to other practices, such as mutilation or weighing bodies down with stones, that were believed to thwart vampires and the undead by preventing them from escaping their graves. But Alterauge says no one had looked systematically at the phenomenon of prone burials in medieval German-speaking areas that now constitute modern Switzerland, Germany, and Austria.

Now, in a new study published in the journal PLOS One, Alterauge’s research team reveals their analysis of nearly 100 prone burials over the course of 900 years that have been documented by archaeologists in German-speaking Europe. The data suggest a major shift in burial practices that the researchers link to deaths from plagues and a belief among survivors that victims might come back to haunt the living.

A medieval burial in a Berlin churchyard reveals a man buried face down. Prone burials increased in the later Middle Ages and may be a reaction to deaths resulting from the plague.

During the early and high Middle Ages in Europe (ca 950 to 1300), the few bodies that were buried face-down in regional graveyards were often placed at the center of church cemeteries, or even inside the holy structures. Some of them were buried with jewelry, fine clothes and writing implements, suggesting that high-ranking nobles and priests may have chosen to be buried that way as a display of humility before God. One historical example is Pepin the Short, Charlemagne’s father, who reportedly asked to be buried face-down in front of a cathedral in 768 as penance for his father’s sins.

Archaeologists begin to see an increase in face-down burials in Europe by the early 1300s, however, including some on the outskirts of consecrated Christian burial grounds. This shift coincided with devastating plagues that swept across Europe beginning in 1347, killing millions across the continent.

“Something changes,” says Alterauge, who is also a doctoral student at the University of Heidelberg.

As diseases killed people faster than communities could cope, the sight and sound of decomposing bodies became a familiar, unsettling presence. Corpses would bloat and shift, and gas-filled intestines of the dead made disturbing, unexpected noises. Flesh decayed and desiccated in inexplicable ways, making hair and nails seem to grow as the flesh around them shriveled.

Decaying “bodies move, they make smacking sounds. It might seem as if they’re eating themselves and their burial shrouds,” Alterauge says.

A 14th-century drawing depicts the burial of plague victims. German tales tell of nachzehrer (loosely translated as corpse devourers), and wiedergänger (“those who walk again”), which may have been inspired by mass deaths resulting from the plague.

As medieval Europeans tried to explain what they were seeing and hearing, they might have seized on ideas about the undead already circulating in Slavic communities of Eastern Europe: “We don’t have [the concept of] vampires in Germany,” Alterauge says, “but there’s this idea of corpses which move around” that is imported into western Europe from Slavic areas to the east not long after the first plague outbreaks take place in the mid-1300s.

A logic behind the undead

Before the 1300s, medieval stories in German-speaking Europe described helpful ghosts returning to warn or help their loved ones. But in an age of epidemics they took on a different shape: revenants, or the walking dead.

“This shift to evil spirits takes place around 1300 or 1400,” says Matthias Toplak, an archaeologist at the University of Tübingen in Germany who was not involved with the study.

Turning to medieval folklore for clues, Alterauge and her co-authors found tales of nachzehrer, loosely translated as corpse devourers: restless, hungry corpses that consumed themselves and their burial shrouds, and drained the life force from their surviving relatives in the process.

“Historical sources say nachzehrer resulted from unusual or unexpected death,” Alterauge says. “There was a theory someone became a nachzehrer if he was the first of the community to die during an epidemic.”

In pandemic-era Europe, the legend had a compelling logic: As the victim’s close relatives began developing symptoms and collapsing within days of the funeral, it must have seemed as if they were being cursed from the grave.

“The background of all these supernatural beliefs must be the sudden deaths of several individuals from one society,” says Toplak. “It makes sense that people blamed supernatural spirits and took measures to prevent the dead from returning.”

Equally feared at the time were wiedergänger, or “those who walk again”—corpses capable of emerging from the grave to stalk their communities. “When you did something wrong, couldn’t finish your business in life because of an unexpected death, or have to atone or avenge something you might become a wiedergänger,” Alterauge explains.

The new study reveals an increase in the number of bodies placed face-down on the edges of Christian cemeteries between the 14th and 17th centuries. The researchers argue that, in this part of Europe at least, burying people face-down was the preferred way to prevent malevolent corpses from returning to do harm.

Other archaeologists say there could be other explanations. In a world ravaged by deadly pandemics, burying the community’s first victim face-down might have been symbolic, a desperate attempt to ward off further calamity.

“If someone got really sick, it must have seemed like a punishment from God,” says Petar Parvanov, an archaeologist at Central European University in Budapest who was not involved in the study. “Prone burials were a way to point out something to the people at the funeral—somehow the society allowed too much sin, so they want to show penance.”

The next step, says archaeologist Sandra Lösch, co-author of the paper and head of the department of physical anthropology at the Institute of Forensic Medicine at Bern University, would be to look at the face-down burials to find if there are clearer links with disease outbreaks. By analyzing the ancient DNA of individuals in prone burials, for example, it might be possible to sequence specific plague microbes, while isotopic analysis of victims’ bones and teeth “might show traces of a diet or geographic origin different from the rest of the population,” offering another explanation for their out-of-the-ordinary burials.

Because local excavation records are often unpublished, Alterauge hopes more evidence will emerge in the years to come as archaeologists re-examine old evidence or look at unusual medieval burials with a fresh perspective. “I definitely think there are more examples out there,” she says.

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