Laurie Kilmartin is a stand-up comic and longtime writer for Conan O’Brien. When her dad was dying in 2014, she live-tweeted his hospice care with an incredible sense of humor. After he died, she released a comedy special called, 45 Jokes About My Dead Dad, a tender and hilarious special that tackles the issues of dealing with death and dying head-on. Later, she wrote a humorous book about death and grief called, Dead People Suck: A Guide for Survivors of the Newly Departed.
On June 18, 2020, Laurie’s mom died after a short and intense battle with COVID-19. And for a week or so before, Laurie live-tweeted the whole experience of spending her mom’s last moments with her on an iPad. Her tweets are equal parts hilarious and heartbreaking, not to mention full of righteous anger about the COVID-19 crisis and the way some people are denying it’s an issue.
The sense of humor with which she was able to approach the situation is so admirable, and the vast majority of people were extremely supportive. Still, Laurie had to deal with some snide comments from persnickety people in her mentions.
“I hope she doesn’t see your Twitter account,” one person wrote, speaking about Laurie’s mom. “She won’t, because she’d dying,” Laurie simply responded.
For several days, Laurie and her sister sat with their mom on FaceTime, connected through an iPad. Her mom had entered a skilled nursing home for a bad hip injury, and it was there that she contracted COVID-19.
“When we knew we had to put her in one for strength building, they’re all closed or they all have had COVID outbreaks, so they’re not taking any people,” Laurie told ABC7. “I was given two options, and one was an hour away and one was kind of close. And I picked the close one, and they had a COVID outbreak.”
“The day after mom entered her nursing facility, there was one case of COVID,” Laurie tweeted. “I just called, now there are 50 cases of COVID associated with this facility, employees and patients. Ten days later. This is Highland Park, in Los Angeles.” In another tweet, she wrote, “Thinking I should have sent my mom to recover at a meat-packing plant instead.”
She and her sister fought extremely hard to get to visit their mom. The hospital she was being treated at stopped allowing visitors because of the pandemic, but Laurie rallied friends and fans to contact the hospital, and eventually, they modified their rules. Laurie and her sister were able to spend about an hour with her mom on the Monday before she died.
The rest of the time, they were stuck on the iPad. Much of Laurie’s very understandable anger about her mom’s death on Twitter has been directed at those who still refuse to wear masks to help prevent the spread of the virus, notably, former baseball played Aubrey Huff.
He tweeted saying that he would no longer wear a mask inside any business because “it’s unconstitutional to enforce.” Laurie wryly responded that she was in the midst of watching her mom die of COVID-19 and that “her bed will be ready for you in 12-24 hours.” She then posted an update once her mom had passed that just said, “The bed’s available.”
Laurie lamented that even after her mom died of COVID-19, she still has family members who believe that the mandate to wear masks in public is “unconstitutional.” Wearing masks has been proven as an effective way to protect communities from the spread of COVID-19.
It’s a simple, easy thing to do to protect others, and anyone who isn’t willing to is saying that they just don’t care about other people. “In lieu of flowers,” Laurie tweeted after her mom’s death, “the family asks that you throw hot coffee on the face of anyone not wearing a mask.”
For centuries Bali’s Trunyanese people have left their dead to decompose in the open, the bodies placed in bamboo cages until only the skeletons remain.
It is a ritual they haven’t given up — even as the COVID-19 pandemic upends burial practices worldwide with religious leaders in protective gear, cemetary workers in hazmat suits, and mourners banned or unable to comfort each other because of social-distancing rules.
Across Indonesia funeral workers are now required to wear protective equipment and bodies are laid to rest quickly, all in a bid to prevent the spread of the deadly respiratory disease.
But in Bali local officials claim the novel coronavirus, which has infected at least eight million and killed more than 430,000 globally, has yet to reach the remote north east where the Trunyan live.
“The funeral process remains the same but now we have to wear masks,” explained village head Wayan Arjuna.
Tourists are temporarily banned from visiting for fear of them bringing in the disease, he adds.
“We’re afraid of getting COVID-19,” said Arjuna, but added there was no suggestion of stopping the open-air burial process.
Unlike many in the rest of Hindu-majority Bali, the Trunyanese — who fuse animist beliefs and traditional village customs with their own interpretation of Hinduism — do not bury or cremate their dead.
Instead they let nature take its course as the corpses decay in the open, believing it to be a way to keep a link with the deceased.
“This makes us feel connected to our loved ones,” Arjuna said.
“Like when my grandmother died, I felt like she was close”, he added.
– Skull Island –
It is a short boat ride to their open-air cemetery from tiny Trunyan village, overlooked by volcano Mount Batur and a sprawling Hindu temple carved out of volcanic rock.
There are 11 cages for the corpses — placed close to a fragrant banyan tree that hides the putrid smell of death, locals say.
In one cage, a recently deceased woman could almost have been mistaken for someone sleeping, but her waxy greying complexion revealed the truth.
Nearby, a flesh-less foot poked out of clothing left on the bodies, while a skeletal jaw lay agape in another cage.
“I used to be a little scared working here, but it’s been so long now that I’m used to it,” said veteran guide Wayan Sukarmin, who was spent 20 years showing people the custom on what outsiders have dubbed “Skull Island”.
When AFP visited in February before the World Health Organisation declared a pandemic and travel restrictions were put in place, signs warned visitors to wear appropriate clothing and refrain from using bad language.
Rubber sandals, cigarette packages, toothpaste tubes and pots and pans were scattered around the site, along with baskets filled with coins and crumpled money — all left by mourners for dead relatives to use in the afterlife.
“Locals won’t take anything because it belongs to the dead. That’s our belief,” Sukarmin said.
“I don’t know what the consequences would be if you took something but I believe in karma,” he added.
– Millennia-old custom –
If the cages become full then older corpses are moved to an open ossuary, to make way for new ones.
Then when there is no flesh left, the skulls of the long dead are placed upon a stone altar, until they too crumble back into nature.
Nearby, there is a second cemetery for the unmarried and children, while a third location is for those who died unnatural deaths like murder or passed away from acute illness.
The Bali Aga — or mountain people — who live in these isolated villages, claim to be descendents of the original Balinese and the main temple in Trunyan village dates back to the 10th century according to historical records.
The origin of the custom of open-air burials is subject to debate.
One legend has it that the area’s early inhabitants fought over the prized Banyan tree, so to keep the peace, leaders decided to place the dead there, believing the smell from the corpses would make the spot less attractive.
Another story suggests that the ritual was adopted to avoid angering the rumbling volcano nearby by cremating people.
“There are several versions of the legend so I can’t decide which one is correct,” Arjuna said.
But these open-air burials are now so rooted in the culture that few expect much to change in Trunyan, even as the pandemic ravages the world.
“It’s relatively easier to prevent infections in isolated and faraway places,” said Bali’s virus taskforce chief Dewa Made Indra.
“There aren’t any reported cases in Trunyan. But if that happens then we’ll handle it with special procedures and I think the villagers will understand.”
When the coronavirus came to Boston, doctors at Brigham and Women’s Hospital noticed how silent certain floors became. Any patients who could be discharged were discharged. Anyone who could stay away stayed away. “The hospital had this eerie quiet,” says Jane deLima Thomas, the director of palliative care at Brigham and Women’s Hospital and Dana-Farber Cancer Institute. But in the intensive-care units set up for COVID-19, machines beeped and whirred in room after room of the sickest patients. Those patients were sedated, intubated, and isolated. Many of them would die.
Palliative care is about providing comfort—physical and emotional—to patients who are seriously ill, including those who may be close to death. Before the pandemic, deLima Thomas’s team worked with patients with kidney disease or cancer or heart failure, but this spring, they all switched to COVID-19. They embedded themselves in the ICUs. Palliative care is a field especially invested in the power of a hug, a steadying hand, and a smile. In other words, palliative care is made especially difficult by a virus that spreads through human contact.
The first day the palliative-care doctors walked into the ICUs, Thomas says, “we felt like tourists.” They were dressed in business casual, while their ICU colleagues raced around in scrubs and masks. But the palliative-care team—which includes physicians, nurses, chaplains, and social workers—found ways to integrate themselves. In the early days of the pandemic, when protective gear was scarce, no visitors were allowed. Palliative caregivers, along with ICU nurses, held iPads cocooned in plastic bags so families could say goodbye on Zoom. They were sometimes the only one in the room when a patient died, otherwise alone. I interviewed several members of the Boston-based palliative-care team, and their stories, which have been condensed and edited for clarity, are below.
Samantha Gelfand, Fellow
In the ICU, the most immediate thing is the personal experience of walking down the hall. Nearly every patient’s room, the door is closed, and the patient is alone. And they’re often on their bellies for prone positioning. You can’t even see their faces often.
Seeing anyone who is critically ill with a breathing tube, lots of monitors and beeping, it’s not easy. When we facilitate Zoom calls with family, I say, “Listen, it may be alarming to see that your loved one has tubes and tape and monitors on their head.” They may have soft wrist guards on their arms to stop them from trying to take out their own tubes.
It doesn’t always work. I did a Zoom call with seven family members. The patient was a man in his 50s and he had seven kids, and they ranged from 18 to late 20s. I told the siblings what I could to prepare them, and still I’m holding the iPad and they start wailing. There’s a visceral experience of just devastation.
As someone’s who lost my own parent, I think wailing is appropriate. I let them. I actually think holding the silence and bearing witness is the right thing to do first. It’s very uncomfortable to watch, but I think it’s misguided to try to hush or try to shorten it. How do you comfort someone on Zoom? It sucks.
Our department has a reflection conference on Tuesday mornings. In COVID-19 times, we’re still doing this, but now we’re doing it by Zoom. One clinician will read the names of patients who died last week in our care. It’s very, very eerie to hear the list of names and have worked with probably half of them and not have seen their faces.
Usually when we sit in that room and we remember the dead, we are remembering what it felt like to talk to them, what they looked like. And this, it’s like we’re remembering what it felt like to think about the patient or what their family members’ voices sound like. I really missed the times when I could think of a face the patient made or a comment that they said. It feels like a new way of grieving.
Ricky Leiter, Attending Physician
COVID-19 doesn’t just affect individuals. It’s affecting families. I’ve had a couple cases where a married couple is in the ICU, next to each other. I was talking to a daughter whose parents were both intubated in the ICU. They were in their 70s to late 80s. Her father wasn’t doing well, and we were asking, “Should we try to resuscitate?”
I remember her saying, “I can’t think about the hard stuff right now. This is all too much right now. I can’t do that.” And of course she couldn’t. How could she? Her parents were relatively healthy before they came in. It was the suddenness of all this. In my normal palliative-care practice, those are patients who have been sick for a while. They have been diagnosed with a serious and life-limiting illness. A lot of COVID-19 patients are otherwise pretty healthy; maybe they have high blood pressure. This is an entirely new universe.
One of our fellows did five or six tough conversations like this with families in one day. I had a day like that early on. Our team walked back to our office, and everyone there asked what happened to us. We were so shell-shocked, and it felt like we were having the same conversations over and over. I don’t normally have six conversations where it’s the same disease, the same coronavirus.
Reverend John Kearns, Chaplain
My brother died 30 years ago this September. It was a life-changing experience and really oriented me into the life of loss and grief. He died of AIDS, which seems so similar now with the fears surrounding an illness that wasn’t well understood. People then were afraid to touch him or hug him. My parents were very dedicated to his care. He died at home in our bedroom that we shared as brothers.
It’s natural for people to take care of their loved one when someone’s sick. Being present for someone is part of what helps people get through it. They’re participating in some way. During this, the families have none of that participating. The first few weeks of COVID-19, we didn’t go inside the patients’ rooms. Now that we have more protective gear, they’ll let us go in, and the department has developed an iPad ministry to connect patients with family who can’t be at the bedside. Sometimes the family will email photographs and we’ll print them out and hang them in the room—photographs of the patients’ kids, wife, spouse, partner. Whether these sedated patients can see or hear is questionable, but the family gets to see, or the family gets to speak to them.
I’ve spent as much as two hours in a patient’s room. I’ve gently wiped the forehead of a patient. I’ve led prayers with the family over the patient. And they will ask us to hold their loved one’s hand. Often there’s a hope to see there’s a response, whether it’s a simple squeeze of a hand, a blink, the movement of the head—anything that gives them hope that their loved one is going to make it.
When the family wants to be seen by the patient, then you have to do the reverse camera and then hold it in such a way that they can see the patient’s face. You’re trying to orchestrate this intimate moment and sacred moment, and you’re fumbling with this iPad. Where is the camera lens on these things? And at first, we were putting these iPads in plastic bags, like a Ziploc bag, to keep it from getting germs on it. So now it’s sliding around in this bag that’s a little too big. You also have the problem of fogging up your glasses and fogging up the shield. At times, it is hard to see the face of the person or to read something or to manipulate the iPad.
There was a Muslim patient who was dying. We have a couple imams. One is actually out of the country; he has not been able to get home since COVID-19 started. The other imam wasn’t available. When the patient took a bad turn, I got called in by Ricky Leiter. As an interfaith chaplain, we also visit everyone. I had an iPad with 20 or so family members who were all over the globe. They were reciting prayers. At one point it reminded me of church bells. All those voices all over the world, coming together at the same time.
Stephanie Brook Kiser, Fellow
I’ve had family members say to me, Just please go in person and tell them in person that I love them and promise me that they won’t die alone, that you’ll be there at the bedside.
A patient I took care had been sick with COVID-19 and in the hospital for two or three weeks. He was 80 years old. His wife was just a few years younger. They had been together since they were teenagers. You can just tell in her voice that it was so hard for her to be apart from him. She said, “I can’t remember a time I’ve been apart from him for this long. I think this might be the first time since I’ve known him.” At the same time, she was living in fear in her home because she knew she had been exposed to him. Because of her age and other medical problems, she was at high risk to be at the same place he was: really sick in the ICU, with a breathing tube, not getting better at two weeks or three weeks.
It was pretty clear medically, no matter what we were doing, he was continuing to get worse and worse and worse. We had a really difficult conversation over the phone about what his wishes would be, and it was clear to her and to their children that the biggest thing we could do was transition to focus on his comfort. We knew what that would mean is he would die pretty quickly.<
With the hospitals’ changing policy, if someone is actively dying, we can now allow for a family member too at the bedside. My experience in the ICU when that’s offered, more times than not family members actually say no, that they don’t actually want to come to the ICU. There’s a real infectious risk to them, and I’ve had a lot of family members say, “I don’t know that I want to see them again the way they are now. I want to remember them the way they were before.” The wife was in such distress and despair over the idea that she was so physically close in Boston but it wasn’t the right decision for her to come into the hospital. I spent a lot of time and I was even grasping at things: Can I arrange a Zoom call? Maybe I can record a video and send it to you guys? And the family was saying, We want to remember him in a different way.
They said, We just want you to go to his bedside and hold his hand so that he knows he’s not alone. And I did that over the course of about 15 minutes. He died pretty quickly.
I’ve been part of a lot of deaths of patients in palliative care. We don’t see a lot of death like this—without any family members present. We aren’t used to being that person at the bedside, trying our best to provide the comfort that a family member’s presence would provide and feeling inadequate in that at best. Afterwards I gathered his nurses and respiratory therapist and we talked. Everyone agreed it was unlike anything they had been part of.
It was the first time I had touched him. And in the ICU, probably one of the only times I’ve physically touched the patient.
Natasha Lever, Palliative-Care Nurse
I’ve been a nurse practitioner for seven years, and I was hired at Brigham to do heart-failure and palliative care. Literally the week after I started, COVID-19 happened. They had this whole very carefully planned out 12-week orientation, and I got a phone call from our director, Jane, and she said, “Either we’re going to keep you at home for the next few months or we’re just going to put you in the ICU.” I kind of got thrown into the deep end.
I went into nursing because I love to be at the bedside and with patients. Not having families and loved ones at the bedside was probably the most difficult part of all of this. It felt so wrong to us that families were having to make decisions about withdrawing care when they haven’t seen their loved ones.
I remember the one that hit me the most was a woman whose son had given her COVID-19. He had been quite ill himself, and he had recovered. The immense guilt that he felt was so profound. He kept saying—he’d obviously been watching the news—“Please, don’t throw her in a body bag if she dies.” He kept talking about how they had been so excited they were going to move into a house together and he was going to buy his first house. He had plans for her and just wanted her home so badly. She passed away and it was very difficult.
That was one of my first cases. And this was week two of my job as a palliative-care practitioner.
I remember the first day I was in the ICU, it was completely chaos. It was very loud, lots of people. Almost this adrenaline rush you felt. A couple of weeks in, things sort of settled down. Now the ICU numbers are down. I had a really strange feeling when they were closing down the COVID-19 ICUs. I walked down the hallway and it was dark and all the rooms were empty and clean and there was no one there. Two weeks ago, this was one of the most busy, chaotic places in the hospital and there was just this silence. No alarms, and no people. It was almost as though, Is this a dream, did that really happen?
Now I have just started doing the orientation that I was supposed to be doing. I’m going back to the hospital. I’m extremely excited to be at the bedside. I have never been so excited to talk to a patient in real life.
Outbreaks of coronavirus have hit prison populations particularly hard – but for many inmates in the U.S., illness and the prospect of dying behind bars already existed.
Advocacy groups have flagged concerns about disease transmission, lack of medical care and deaths in custody as a result of COVID-19. But deaths in custody are not a new phenomena and the process of dying with dignity while incarcerated is complicated.
I have spent a significant amount of time examining correctional health care practices and believe the process of dying in prison is one in which human dignity can be lost.
Prisoners grow old faster and become sick earlier. By 2030 some experts believe that one in three prisoners will be over the age of 55, increasing the likely population of prisoners diagnosed with conditions such as cancer, heart disease, liver and kidney disease, high blood pressure and diabetes.
A recent Bureau of Justice Statistics report revealed a startling increase in state prisoner mortality. Between 2006 and 2016, the last year for which the study provided data, there were more than 53,000 deaths in custody. More than half of the 3,739 deaths in custody in 2016 resulted from just two illnesses – cancer (30%) and heart disease (28%).
The proportion of prisoners requiring end-of-life care is twice as high as the general population.
An inmate with cancer in Colorado Territorial Correctional Facility’s hospice program.
Outside prison walls, a diagnosis of a terminal illness often means gathering friends and family to repair and restore relationships and thinking about end-of-life options. The coronavirus has, of course, affected who can be present in someone’s last moments, but the terminally ill still have options over their medical care, pain management, who to tell and how, and getting affairs in order. For prisoners, such choices are constrained by state regulation. Prisons are not well-equipped to provide human dignity at the end of life. Terminally ill prisoners have two options: compassionate release or end-of-life care behind bars.
Showing compassion
Offering early release or parole to prisoners diagnosed with debilitating, serious and often terminal illnesses is considered compassionate release. Many in the medical profession consider compassionate release a constitutionally protected right as incarceration of prisoners with debilitating illness undermines medical care and human dignity. Others see compassionate release as a way to reduce correctional health care costs for a population posing little risk to the public. Iowa is the only state without a compassionate release law.
The process of qualifying for compassionate release is complex and statistics on how many succeed are hard to obtain, although we know the numbers are small. Prisoners’ medical conditions, age and time served determine eligibility. But exclusion criteria are extensive. For example, prisoners committing the most serious crimes are excluded. Most states allow stakeholders such as victims, police and court professionals an opportunity to say no.
For the terminally ill, release is often dependent on one’s “death clock” – how many months a medical professional certifies that you likely have before dying. In some states like Kansas and Louisiana, death must be imminent – within 30 to 60 days. In others like Massachusetts and Rhode Island, prisoners with as long as 18 months to live may be released. Applying for compassionate release can be daunting for someone with only months to live. Sadly, some die before they can complete the process.
Even if an inmate does get out, their family may be ill-equipped to deal with the challenges of caring for a dying loved one. In these cases, release may result in transition from one restrictive, isolated, institutional setting to another with care provided by unfamiliar medical professionals.
End-of-life sentence
States must provide medical care to prisoners even though they are being punished for a crime. But the quality of such care is often inadequate. The prisoner does not get to select medical options; care is determined by the state. Death could mean dying alone in a prison cell, in an infirmary with only periodic check-ins from a nurse and prison volunteers or in a hospice unit managed by the state.
Pain management may be restricted by correctional policy and by staff who are reluctant to administer narcotics, such as morphine, to ease suffering out of concern that it could be sold or used illicitly. A recent report in the American Society of Clinical Oncology Post discussed how inadequate care caused unnecessary pain and suffering in prison and concluded: “No one in a wealthy and socially advanced country like the United States should suffer from untreated pain, especially at the end of life.”
While families are allowed to visit terminally ill prisoners, notification of the illness rests with the prisoner – a daunting task if the prisoner has lost touch with relatives over years incarcerated. State prisoners are often confined far from home, so even family members who would like to visit may be hampered by distance and cost. Another challenge for families is the bureaucratic process of prison admission. It is correctional staff at the gates rather than medical professionals determining who gets to visit on any given day.
Access to a mainstream faith leaders and last rites are provided when available. But it is not uncommon to find spiritual practices for the dying prisoner carried out by fellow prisoners.
For terminally ill prisoners “getting one’s affairs in order” includes trying to identify someone in the community willing to take responsibility for their body after death and ownership of personal effects gathered during incarceration. Even if the prisoner identifies a relative willing to take responsibility, there are no guarantees. A relative may be disqualified from handling prisoner affairs. In Ohio, for example, if the prisoner’s loved one is unable to accept the body within two days after notification, the relative may be disqualified.
If no one comes forward, then the prisoner will be buried in an indigent grave and prison officials will dispose of the prisoner’s belongings and monies remaining on prisoner accounts.
On a recent Monday in a New Jersey cemetery, social worker Jane Blumenstein held a laptop with the screen facing a gravesite. A funeral was being held over Zoom, for a woman who died of COVID-19. It was a brilliantly sunny day, so a funeral worker held an umbrella over Blumenstein to shield the laptop from any glare, as synagogue members and family members of the deceased sang and said prayers.
The experience was a “surreal” one for Blumenstein, who is a synagogue liaison at Dorot, a social-services organization that works with the elderly in the New York City area. “I felt really privileged that I could be there and be the person who was allowing this to be transmitted.”
The roughly 20-minute ceremony was one of countless funerals that have taken place over Zoom during the COVID-19 pandemic. As authorities limit the size of gatherings — and hospitals limit visitors in order to prevent the spread of the novel coronavirus — loved ones have been unable to gather for traditional mourning rituals in the aftermath of a death, so it has become the norm for those who die to do so without their families by their sides, able to say goodbye only virtually, if at all.
The rising death toll has overwhelmed funeral homes and cemeteries, further limiting what is possible. Across religions and around the world, end-of-life traditions have been rendered impossible: stay-at-home orders have stopped Jewish people from sitting shiva together; overwhelmed funeral services have meant Islam’s ritual washing of the body has been skipped; Catholic priests may have had to settle for drive-through funerals, in which the coffin is blessed in front of just a few immediate family members.
The effects of COVID-19 will be felt for many years to come, but those who have lost loved ones are feeling those effects immediately — and, for many, their pain has been exacerbated by the inability to say goodbye. The horror of these rushed goodbyes may be looked back on as a defining feature of the COVID-19 pandemic. But, as the tragic history of pandemics reveals, it is something that disease has forced human beings to struggle with throughout history.
For example, during a 1713 plague epidemic in Prague, a shortage of burial supplies heightened the pain of rushed burials. The emotional toll is evident in a Yiddish poem written shortly after the outbreak, translated for TIME by Joshua Teplitsky, professor of History at Stony Brook University, who is writing a book about this period. At the sight of the dead being carried away day and night, “all weep and wail!,” the poem says. “Who ever heard of such a thing in all his life?” The poem describes people working around the clock and through the Sabbath to saw planks for coffins and sew shrouds.
In one 1719 book, a rabbi recalls counseling a man who was anxious about burying his plague-stricken father in the local cemetery because of a government requirement to coat the body in a chemical to accelerate decomposition. He asked the rabbi if it would be more respectful to bury his father in a forest far outside of the city. The rabbi told the man to follow the rules, likely thinking that “if the body gets buried in the woods, in a very short time, it will be lost, and if it’s in the cemetery, the rabbi is expecting that when this plague passes, visitors will go pray and pay their respects,” says Teplitsky.
Indeed, Teplitsky found a prayer printed circa 1718-1719 that he believes women may have recited while walking around a cemetery years after the epidemic, asking the dead for forgiveness for the lack of a traditional funeral and burial five years earlier.
Centuries later, during the 1918-1919 flu pandemic, Italians were likewise thrust into a world in which funerals had to take place quickly, without ceremonies or religious rites. According to research by Eugenia Tognotti, an expert in public health and quarantine, and a professor of history of medicine and human sciences at the University of Sassari, Italy, many expressed horror at hurried burials in letters to friends and relatives, which are preserved at the Central State Archive in Rome. “The more common lamentations are: ‘Not priests, nor crosses, nor bells’ and ‘one dies like an animal without the consolation of family and friends,’” Tognotti told TIME. Another woman wrote to a relative in Topsfield, Mass., “Here [in Italy] there is a mortal disease named Spanish flu: the sick die in four or more days, a bucket of lime is thrown over the dead bodies, and then four workers take them to the graves like dogs.”
The horror was similar in the U.S., especially in Philadelphia, an epicenter of the pandemic. Columba Voltz was an 8-year-old daughter of a tailor back then, who said that funeral bells tolled all day long as coffins were carried into a local church for a quick blessing and then carried out a few minutes later, according to Catharine Arnold’s Pandemic 1918: Eyewitness Accounts from the Greatest Medical Holocaust in Modern History. “I was very scared and depressed. I thought the world was coming to an end,” Voltz recounted.
Inside one such house, Anna Milani’s parents laid her 2-year-old brother Harry to rest with what they had on hand:
There were no embalmers, so my parents covered Harry with ice. There were no coffins, just boxes painted white. My parents put Harry in a box. My mother wanted him dressed in white — it had to be white. So she dressed him in a little white suit and put him in the box. You’d think he was sleeping. We all said a little prayer. The priest came over and blessed him. I remember my mother putting in a white piece of cloth over his face; then they closed the box. They put Harry in a little wagon, drawn by a horse. Only my father and uncle were allowed to go to the cemetery. When they got there, two soldiers lowered Harry into a hole.
The same concerns that would have limited attendance at the cemetery when Harry Milani was buried reared their heads more recently during the 2014-2016 epidemic of Ebola, a disease that can be spread through contact with the remains of those it kills. More than 300 cases came from one Sierra Leone funeral, and 60% of Guinea cases came from burial practices, according to the World Health Organization. In Liberia, mass cremations ran counter to traditional burial practices that include close contact with bodies. In Sierra Leone, the dead were put in body bags, sprayed with chlorine and buried in a separate cemetery designated for these victims. As traditional burial practices were curbed in an attempt to stop the spread, the dismay caused by this situation, Tognotti notes, was the same feeling experienced by those Italians of the early 20th century who wrote of the pain of the flu pandemic.
Sometimes, however, victims of epidemics who knew the end was near were actually hoping for a departure from the usual norms of burial and mourning: they wanted their deaths to be used to remind authorities to take these crises seriously.
This idea of the political funeral is particularly associated with the AIDS epidemic of the 1980s and 1990s. The activist group ACT UP spread the ashes of victims over the White House lawn, and staged political funerals—open-casket processions, such as the one that brought Mark Lowe Fisher’s body to the Republican National Committee’s NYC headquarters ahead of the 1992 presidential election. “I have decided that when I die I want my fellow AIDS activists to execute my wishes for my political funeral,” Fisher wrote, in a statement entitled Bury Me Furiously. “We are not just spiraling statistics; we are people who have lives, who have purpose, who have lovers, friends and families. And we are dying of a disease maintained by a degree of criminal neglect so enormous that it amounts to genocide.”
The inability to give loved ones proper send-offs is often a hidden cost of these pandemics, Tognotti says, and should not be ignored by officials. Even with modern knowledge about disease transmission, awareness of the reasons for public-health guidance doesn’t lessen the desire to participate in rituals. “The emotional strain of not being able to dispose of the dead promptly, and in accordance with cultural and religious customs, has the power to create social distress and unrest and needs to be considered in contemporary pandemic preparedness planning,” she says.
In this pandemic, a new openness about talking about mental health issues could help. For example, New York state launched a hotline so residents can talk to a therapist for free, and some sites host virtual sessions to discuss grief. Mourners can opt for live-streaming and video conferencing and include more people virtually than before.
For others, these virtual gatherings and brief blessings at the cemetery are placeholders. In March, after Alfredo Visioli, 83, was buried in a cemetery near Cremona in northern Italy, with no relatives allowed to attend and a brief blessing from a priest, his grand-daughter Marta Manfredi told Reuters that, “When all this is over, we will give him a real funeral.”
It starts from the moment you pass. Your organs begin to shut down. Hair stops growing, skin recedes. Some parts of the body take longer than others, but eventually, as with all things, it all starts to break down.
If you opt for a traditional burial, your remains will spend years nestled within a casket underground, progressing into a deeper state of decomposition. If you opt for a traditional flame-based cremation, you eliminate any further decomposition by burning it to a halt.
But there’s also another alternative — one designed to accelerate the decomposition process through the medium of water. It’s known as alkaline hydrolysis, or water cremation. One part spa, one part chemical blend, a few hours of a swirling soak, and your earthly remains are no longer.
“It’s basic chemistry,” explains Anas Ghadouani, leader of the research group Aquatic Ecology and Ecosystem Studies. “You have organic matter and you add a base to it and it just decomposes. You can write the equation to it. It’s very simple.”
Despite this, alkaline hydrolysis remains one of the most divisive and misunderstood practices in contemporary funeral technology.
The machine
Alkaline hydrolysis is a form of cremation that uses water and chemicals to break down the human body to its bare minimum. Salts, amino acids, peptides. Like flame-based cremation, it produces ash that can be taken home. Unlike flame-based cremation, it’s illegal for use on human bodies in almost 30 states in America.
The concept itself isn’t new. Amos Herbert Hobson of Middlesex, England, patented the first alkaline hydrolysis machine all the way back in 1888. He used it to dispose of animal carcasses.
In the century and a half since, the technology has evolved, and it has the potential to shake up the death industry.
The process is straightforward. Bodies are placed in a machine containing a chemical mixture of water and alkali. The mixture is then heated and cycled. Over the course of hours, the body is accelerated through its natural decomposition process, resulting in a residual liquid made up of amino acids, peptides, salt, soap and bones — the last of which is broken down into white ash.
Joseph Wilson, now founder and CEO of leading alkaline hydrolysis manufacturer Bio-Response Solutions, helped design the first commercial-use human alkaline hydrolysis unit in 2005.
“I was stunned that there was a way to dispose of tissue without burning,” said Wilson. “You don’t have any external pumps or tanks or chemicals. It’s all there at the machine.”
There are undeniable benefits to this process. In 2011, a study from the University of Groningen compared conventional burial, cremation, alkaline hydrolysis and cryomation and found that alkaline hydrolysis had the lowest overall environmental footprint.
The low temperature also means pacemakers and joint replacements can remain inside the body. In flame-based cremation, these are extracted to prevent a reaction — pacemakers, especially, are incredibly volatile when subjected to extreme heat.
Yet despite the fact that flame-based cremation subjects the remains to intense fire, alkaline hydrolysis is seen as the more graphic option for potential funerals, when both are just as valid. Legal roadblocks and cultural concerns have plagued water cremation since its inception.
And there’s a simple reason for that: Alkaline hydrolysis has a reputation shaped by years of misrepresentation. Nobody wants to feel like they’re disrespecting their loved ones.
Media, morals and the mafia
Most people’s first experience of alkaline hydrolysis is through popular culture.
In the second episode of Breaking Bad, audiences sees drug dealer Jesse Pinkman dissolve a dead body in his apartment’s bathtub using hydrofluoric acid he’d sourced from his high school’s chemical stores. He returns the next day only to find the acid had eaten through the bathtub itself and floorboards beneath, before finally falling through to the floor below.
Despite the effective cinematics, Breaking Bad is far from realistic. Hydrofluoric acid, while highly corrosive, doesn’t have the capacity to completely liquefy remains overnight — it’s at the wrong end of the pH scale. It certainly doesn’t have the capacity to eat through a bath and the floor.
Whether it’s a question of gulping down Soylent Green or shunting bodies into acid barrels, television and film haven’t been kind to the practice of alkaline hydrolysis.
Outside of television, urban legends have tarred alkaline hydrolysis with further negativity. In 2011, researchers had to debunk claims the Sicilian mafia disposed of human remains in a process called lupara bianca, or white shotgun. Just like in Breaking Bad, the mafia supposedly used acid — an entirely different, cruder chemical process.
Mafia urban legends and shows like Breaking Bad create a sense of violence surrounding water cremation that simply doesn’t hold up. Water cremation, at its core, is no more than the acceleration of a natural process.
The reality: As with almost all aspects of the death industry, there is a level of respect and dignity. You don’t see what happens in the retort of a flame-based cremator, but you won’t see what happens inside an alkaline hydrolysis machine either.
Waste not
What remains to be dealt with, however, is what comes out the other side. Ashes are one thing — you can pop them on the mantle in a decorative urn, sprinkle them at sea or even have them launched into space — but what about the residual liquid?
One of the biggest roadblocks to the acceptance of alkaline hydrolysis technology is the issue of wastewater. Because of its association with death, the liquid is perceived as too unsanitary to be processed normally. Say it goes through the same recycling plants that supply residential areas, the idea of drinking the essence of a dead body sounds abhorrent. It’s hard enough swallowing the idea of recycled sewage water. Remains? Inconceivable.
But technology already exists to tackle almost any kind of wastewater.
Sewage water is filtered for reuse in municipal treatment plants. Organic material is broken down in anaerobic digesters, which convert the material into methane or “biogas.” Specially designed ultrafiltration systems can even tackle aqueous nuclear waste.
“Any liquid waste that we have, we can deal with,” says Ghadouani.
Yet in Australia, residual liquid from water cremation isn’t permitted to be treated via the municipal water treatment facilities or digesters. More worryingly, there’s a disconnect here — and it’s one that, for the most part, is behind the closed doors of the funeral industry.
“One of the most common things the public doesn’t know,” says leading US thanatologist and death educator Cole Imperi, “is that when someone is embalmed, all the blood that comes out of your body, where does that go? It goes down the drain.”
In fact, almost all the human waste that comes from hospitals and funeral homes as a result of the embalming process is permitted to be processed through these official channels.
“So if you’re allowing byproducts from funeral homes to go into the municipal water system for treatment, why are you discriminating against one particular disposition method?” Imperi asks. “It’s an interesting kind of cognitive dissonance.”
Thanatologist Cole Imperi beside one of Bio-Response Solutions’ alkaline hydrolysis machines.
Nevertheless, in the few states that allow alkaline hydrolysis — for animals — practicing venues must provide their own wastewater filtration treatments and submit them for regular testing. It’s expensive and demanding. Venues are scarce.
Jonathan Hopkins, owner and operator of Resting Pets Cremations in New South Wales, Australia, is an alkaline hydrolysis advocate. He and his late wife opened their practice after the pain of a family pet’s death opened their eyes to the process as a cremation alternative.
“My wife was always an animal lover and she just had a really bad experience with the [cremation] company that was serving this area,” he said. “So we approached the local council for a pet cremation system.” They landed on alkaline hydrolysis.
To ensure the wastewater passed council and environmental regulations, Hopkins created his own treatment system. He began by increasing the machine’s existing filtration capacity, with any overflow going into a separate tank. Here, microorganisms remove any remaining bacteria — much like a septic system.
“With our system, they can see what chemicals are going in, and they can see the effluent coming out. They can test it, they know where it’s going,” he said.
Reframing the narrative
Some will always struggle with the concept of alkaline hydrolysis. Certain cultures or religions might always register a stronger connection to conventional burial and cremation methods.
But our human instinct to process death isn’t incompatible with water cremation. We could use residual liquid from the hydrolysis process to help nurture the earth. A gardener, for example, could live on in the plants and flowers they once nurtured.
Conceptually, it’s not out of the question. “If the liquid waste stream were to be applied to soil as a fertilizer, there could be a role for this as a soil improver.” explains Michael Short, a senior research fellow of the Future Industries Institute at the University of South Australia.
On a larger scale, this could even benefit the wider agricultural industry.
“The wastewater stream [would be] a relatively high strength organic waste solution,” Short says. “Soils in some Australian regions are generally low in natural organic matter, so adding organics from such waste streams could help to improve overall soil quality and soil carbon stocks.”
It may sound strange on first pass, but why not? If it gives someone peace of mind that our loved ones will “live on,” the transmutation of alkaline hydrolysis liquid to fertilizer may just be the PR dream the technology has been waiting for.
Alkaline hydrolysis may not be accepted anytime soon. It may take years of building up a more positive association. Maybe even decades.
It all comes down to whether states and countries are willing to test the waters.
When Raj Singh’s 70-year-old mother died from the coronavirus in India’s capital, he took comfort in the prospect of a proper cremation, the funeral rite that Hindus believe releases the soul from the cycle of rebirth.
But instead of chanting sacred Vedic hymns and sprinkling holy water from the Ganges River, all Singh could do was place his mother’s wrapped corpse on a wooden pyre and along with a handful of relatives watch it burn.
“I never thought I would watch my mother go like this,” he said.
Like elsewhere in the world, the novel coronavirus has made honoring the dead in New Delhi a hurried affair, largely devoid of the rituals that give it meaning for mourners. Cemeteries and crematoriums are overwhelmed, so there isn’t much time for ceremony, and even if there were, the government limits the number of people allowed at funerals and those in attendance must maintain distance and wear masks.
“The whole grieving process has been interrupted,” said Pappu, who goes by only one name and lights the funeral pyres at Nigambodh Ghat, New Delhi’s biggest crematorium.
New Delhi has officially reported close to 1,100 deaths from the coronavirus, but cemeteries and crematoriums in the city say the actual number is several hundred higher. Hospital morgues are beyond capacity, and with summer temperatures reaching 40 degrees Celsius (104 degrees Farenheit) some bodies are being kept on thick ice slabs.
“In the beginning, I used to carry only one body. Now, helpers at the morgue will stack as many bodies as they can fit in my van,” said Bhijendra Dhigya, who drives a hearse from one New Delhi hospital to the crematorium.
The spike in deaths in New Delhi comes amid a broader virus surge throughout India, where authorities are reporting some 10,000 new infections each day and more than 300 deaths. Nevertheless, India lifted most of the remaining restrictions from its 10-week lockdown on June 8, the same day it recorded what at the time was its highest single-day death toll from the virus.
On Friday, India’s nationwide caseload overtook Britain to became the fourth highest in the world with 297,535 confirmed cases and 8,498 deaths, according to the Health Ministry. But that is just the known cases. Like elsewhere in the world, the actual number of infections is thought to be far higher for a number of reasons including limited testing.
New Delhi’s health centers are under immense strain and the state government’s deputy chief minister, Manish Sisodia, said this week that a state health department model has projected a worst case scenario in which the number of infections in the capital — already at nearly 35,000 — could reach 550,000 by the end of July.
In the worst case scenario, Sisodia said New Delhi would need 80,000 hospital beds, far more than the roughly 9,000 hospital beds currently available for virus patients. The state government is considering taking hotels and sports stadiums to use as field hospitals.
The capital’s Nigambodh Ghat crematorium has handled more than 500 coronavirus cremations since the beginning of the outbreak. When some of its gas-fueled incinerators broke down, there was no one willing to repair them, so the staff reverted to traditional wooden pyres.
Even with working hours extended, there has been no time for individual cremation ceremonies and exhaustive rituals with incense, garlands of marigold and chanting.
The crematorium is now largely quiet except for the distinct snap and crackle of the burning wood and the din of sirens from ambulances bringing more bodies.
The virus has upended Muslim burial rituals in the city as well.
Islamic burials normally involve a simple ceremony. Before the body is laid to rest, it is washed. Those attending the funeral are allowed to have a look at the face of the dead and a prayer is performed, followed by a sermon from a cleric. Then close family members help place the body in a grave.
Now bodies arrive at New Delhi’s largest Muslim cemetery in hearses manned by crews in hazmat suits. Bodies aren’t washed and mourners can’t view them. There are no sermons.
The cemetery has already seen more than 200 burials of COVID-19 victims and with bodies steadily arriving, the grounds are filling fast.
On a recent day at the burial of a 22-year-old man who died of the virus, a backhoe dug a grave as four relatives said a speedy prayer. The body was then lowered into the grave by ropes.
Mohammad Shameem, a gravedigger who now oversees the burials, shook his head in disapproval as the backhoe quickly carved out another grave.
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