Lax procedures, higher costs: Burying the dead amid the coronavirus

On May 22, Gehad Ibrahim’s phone rang at 11 pm. The caller identified himself as an employee in the intensive care department of Abbasseya Fever Hospital and informed Ibrahim that her mother had died a few minutes earlier. He asked Ibrahim to come to the hospital the next morning to complete the burial procedures.

It was a heavy night for Ibrahim. Her grief was multiplied. She grieved for the loss of her 63-year-old mother, and she grieved over what would happen to the body — that she might be deprived of properly saying goodbye to her mother due to the strict procedures around the washing and shrouding of bodies amid the pandemic.

Morning came slowly. Just after dawn, Ibrahim made her way to the hospital. “We went to the hospital early in the morning, and we waited for the patient affairs coordinator until 10 am,” Ibrahim says. “We then received a form that stated that the cause of death was a sharp drop in blood pressure which resulted from pneumonia and cardiomegaly.”

Ibrahim’s mother, Nafisa Badawi, had gone to the Abbasseya Fever Hospital at dawn on the 28th day of Ramadan suffering from high fever and shortness of breath. She had previously tried several private hospitals but they all refused to admit her without a negative PCR test result proving she was not infected with COVID-19.

“We waited for a few hours until someone finally came for her at 5 pm. The doctor took a swab from her for the PCR test and said she needed to be admitted to the ICU immediately,” Ibrahim says. “We waited for a few more hours in the emergency unit until a bed became vacant. She was transferred to a bed the following afternoon. She died a few hours later.”

The next morning, Ibrahim gathered a linen shroud and a bottle of perfume for disinfectant and made her way to the hospital with her father. Her mother’s body had been transferred to the morgue.

Ibrahim’s father took the death certificate from the hospital and went to the corresponding health office, in the 6th District in Nasr City, to obtain a  burial permit, which he quickly received.

Meanwhile, Ibrahim waited in the morgue with the linen shroud in her lap. “While we were waiting for the burial permit, they told us the PCR test result came back negative. I was very happy that it wasn't coronavirus, thank God,” Ibrahim says. “If it was coronavirus, they wouldn’t have allowed us to see her and say goodbye during the washing.”

After they submitted the burial permit at the hospital, the morgue attendant brought the body from the refrigerator to a room for washing. The woman responsible for washing and shrouding female bodies in the hospital informed the family of the costs and asked Ibrahim, her sister, and aunt to accompany her inside.

This was not the first time that Ibrahim attended the washing of a body, but it was certainly the first time in the middle of a pandemic and there was still a possibility, albeit a slim one, that her mother had contracted the coronavirus. Ibrahim expected the washing process to follow stringent procedures she had heard about.

The washing room was equipped simply, with a tap, a bucket, a cup and a bar of soap. Ibrahim said she and her sister had N95 masks on, whereas the female attendant was wearing a normal mask “like the ones they sell in pharmacies for LE5,” and gloves.

After the woman finished washing the body, she wrapped it in three layers of linen and sprayed perfume on the shroud. She then asked the family for an additional tip because she had allowed them to attend the ritual despite the fact that the body may have been infected with COVID-19. 

The woman then asked the family to buy a black body bag specially designed for people who had contracted COVID-19. The family initially refused, saying that the test results had come back negative. The woman said unless they had the test results in hand, the body would be treated as a coronavirus case. The family had not received the actual results so Ibrahim paid an extra LE100 for the body bag bringing the total for the entire procedure to LE1,500.

The woman helped Ibrahim, her sister, and aunt place the body in a wooden casket. They loaded the casket into a hearse and drove to the family cemetery in 15th of May City in southeastern Cairo. 

Apart from the masks that Ibrahim had bought and distributed to everyone who took part in the funeral, she didn’t notice anything different. “Some relatives attended, we prayed for her, and then my uncle and dad buried her,” she says.

The coronavirus pandemic has impacted health care systems around the world, from the treatment and isolation of patients to burial procedures for the dead. When the outbreak hit Egypt in March, the Health Ministry outlined a series of guidelines for dealing with bodies of suspected or confirmed cases of COVID-19. These include extensive protective gear, distancing measures, special body bags, and the monitoring of burials by health ministry officials. 

Yet according to hospital workers and families who have buried relatives amid the pandemic that Mada Masr spoke to, the full protective measures are rarely adhered to and funeral procedures are rarely monitored. Meanwhile, the costs placed on families for burials have risen nevertheless.

******

In March, the Health Ministry outlined a series of measures to be taken with those who die from COVID-19. 

First, the deceased is transferred to the hospital morgue by lifting the body with the bedsheet and placing it on a disinfected medical cart. The team responsible for washing and transporting the body have to wear face masks, gloves, head covers, long plastic boots and a thick gown that covers the arms, chest and legs.

The ministry also identified the steps that should be taken by the team responsible for washing, though it did not specify who was permitted to take part in the washing process. Individuals who do not need to be present are not allowed to enter the washing room. A distance of one meter has to be maintained between all individuals present. Everyone was to wear protective gear and the parts of the dead body that secrete fluids have to be covered with non-porous material.

The ministry guidelines also outlined how to transport the deceased’s body to the cemeteries. “The person who dies as a result of the virus will be transported, after the washing and shrouding, via a hearse or an ambulance, and will be wrapped inside a non-porous bag,” the ministry statement says. “The deceased has to be placed in a closed casket that can be cleaned and disinfected. It is necessary that there are as few people as possible near the deceased, and they have to wear personal protective gear. The casket cannot be opened during the prayer or under any circumstances until the body is about to be buried.”

The ministry also stated that when the casket is opened to take the body to the grave, those carrying out the burial need to wear adequate protective gear, and as few people as possible should be present near the grave. All those present must wash their hands with soap and water afterward for no less than 40 seconds or use an ethyl alcohol-based disinfectant. 

Taking the body out of the non-porous body bag violates the ministry’s preventative measures, as is not adhering to the personal protective gear guidelines. but who is responsible for monitoring the violations, especially in the absence of objections from the families of the deceased? 

An employee in one of the health offices in eastern Cairo, who spoke to Mada Masr on the condition of anonymity, explained the procedures following the death of a person from COVID-19 and before issuing the burial permit. “We report to the medical authority closest to the cemetery of the deceased’s family, and we give them the deceased’s information and the time scheduled for burial. They then take the responsibility to ensure that proper procedures are taken,” he says. 

He goes on to add that the medical authority is responsible for sending a representative from the preventative medicine sector to attend the funeral and ensure that the body is buried with the non-porous body bag and that the grave is 1.5 meters deep. 

The employee, who is responsible for issuing burial permits, remarks that the preventative medicine representatives have stopped attending funerals for a number of reasons. First, the ministry went back and forth regarding transporting the deceased bodies, first by private hearse, then by the ambulance,  then by private hearse again. Second, objections by residents of villages close to cemeteries to the burial of COVID-19 victims in the area subsided, so the representatives stopped going. 

Mada Masr was unable to reach the head of the Directorate of Health Affairs in Cairo, Mohamed Shawky, or head of the Preventative Medicine Sector in the Ministry of Health, Alaa Eid, for comment.

******

On May 26, the third day of the Eid holiday, Emad Aly got a phone call from the ICU in Abbasseya Fever Hospital. His dad had died and he had to go collect the body.

Emad went to the hospital with a few of his father’s relatives that afternoon. “I went to the hospital with my dad’s uncles, and the coordinator gave me a certificate that said he had died from respiratory failure,” Aly says. 

Aly’s father, Aly Ahmed Aly, had been admitted to the Abbasiya Fever Hospital just four days earlier. The 50-year-old had been suffering from high fever and shortness of breath. He was administered a PCR test and admitted to the ICU. 

Aly does not know whether his father tested positive or not. Unlike Ibrahim’s family, Aly’s relatives did not allow the morgue attendant to take part in the washing and shrouding of the body.

“My father’s uncles wash the dead, so they washed and shrouded my father on their own after buying the linen shroud and body bag from the mortician for LE 1,200, a fee that also included transporting the body to the family cemetery in Bahtim” Aly says. 

According to Aly, his father’s uncles bought regular masks from a pharmacy near the hospital and wore them during the washing and shrouding process, then got rid of the masks upon leaving the hospital. 

The lax procedures taken towards Ibrahim and Aly’s deceased relatives could be attributed to the fact that neither were confirmed coronavirus cases. Yet a similar approach was taken in the case of Amna Said, who tested positive for COVID-19 a week before she died on May 22. Perhaps the only difference was that the corpse washer asked for more money.

Said contracted the virus after coming into contact with her daughter-in-law, Amal Sayed, who works as a nurse at Abbasseya Fever Hospital. Sayed contracted COVID-19 during Ramadan and then transmitted the disease to a number of her family members, including Amna Said, who lived with her in the same house. Said was admitted to the hospital when her symptoms began to worsen.

“The attendant asked us for LE7,000  in exchange for washing, shrouding, and transporting the body to the family cemetery in Assiut,” Sayed tells Mada Masr. 

The family negotiated with the attendant and they agreed to pay her LE 1,300 for the washing and shrouding only, and the family would arrange transportation on its own. 

“I went inside with my aunt to help the woman wash my mother-in-law. We shrouded her like any other normal person and put her in a black body bag with a zipper,” Sayed says. “I knew that those who die from the coronavirus had to be washed and shrouded in a specific way, and that the discharges of the body are quite dangerous, but I was too scared and sad so I couldn’t say anything.”

Sayed said the mortician provided her the black body bag for free because she worked at the hospital, though he asked for a tip. Even though Sayed knew that the hospital administration provides a free body bag for victims of COVID-19, she paid the mortician LE 100 as a tip for the bag anyway. Sayed added that because the mortician is selling the body bags and overpricing them, some families have refused to pay him and were content with the simple linen shroud. 

******

The mortician is not a staffed employee of the hospital, but is contracted to manage the morgue and pays a monthly rent of LE 1,000 to the hospital. The hospital administration provides him with the body bags for COVID-19 victims, who are then put inside a wooden casket and taken to the cemetery. 

A medical official in the Abbasseya Fever Hospital, who spoke to Mada Masr on condition of anonymity, said that the Directorate of Health Affairs in Cairo made a deal with the current mortician of the hospital, after training him on the procedures to properly wash and shroud COVID-19 victims. 

“Before the pandemic, the morgue of the Abbasseya Fever Hospital was managed by a retired janitor,” the official says. “They would do the washing, and his wife would wash the women, but they did not get money from the hospital. They relied on what the families of the deceased gave them,” he adds. 

The official, a doctor who heads one of the departments in the Abbasseya Fever Hospital, told Mada Masr that when COVID-19 outbreak hit Egypt in March, the hospital administration realized that the mortician, who is over 70, would not be able to handle the work. So the administration informed the health directorate, which in turn facilitated a tender for morticians and corpse washers that hospitals can work with, and who also own hearses since ambulance stopped transporting the deceased to cemeteries. 

In contrast to what the families of COVID-19 victims told Mada Mar, the medical official at the Abbasseya Fever Hospital —  which receives hundreds of suspected and positive COVID-19 cases each day — did not find the accounts by the families to be in violation of Health Ministry procedures. He only stressed that the mortician had the right to charge for his service on his own without going overboard. 

The Burial Law of 1996 stipulates that any hospital has the right to contract a mortician to prepare and transport the deceased who have no family members. 

Salah Hussein, the ex-mortician at the Abbasseya Fever Hospital, told Mada Masr that since the outbreak of the virus last March, the mortician working with COVID-19 victims receives an average of LE 1,000 to LE 4,000 per body, depending on the financial situation of the deceased’s family. 

Hussein, who decided to retire on May 20, told Mada Masr that before the pandemic, he would receive on average between LE500 and LE600 from the family of the deceased. But after the pandemic, the service expanded to include transporting the deceased to cemeteries. Hussein added that the current mortician renting the morgue at the Abbasseya Fever Hospital also manages the morgue at the Heliopolis Hospital, which was designated as an isolation hospital for COVID-19 patients. He offers transportation services for families at both hospitals. 

Sometimes, relatives of the deceased would do the washing and the shrouding themselves, and the mortician would only provide them with the body bags and only charge them for using the washing room and transportation services. 

Hussein did not specify any special procedures for washing COVID-19 victims. “The body is washed normally, wrapped in a shroud, then put in a body bag before taken to the wooden casket. When we arrive at the cemeteries, the family of the deceased prays, then the body is taken out of the bag and buried, or sometimes it’s buried with the bag,” he said.

As for hospital oversight, the medical official at the Abbasseya Fever Hospital said that the role of the hospital ends at verifying the death of the patient, authorizing their transfer to the morgue, and producing the death certificate. But Suzy Mahfouz, head of the infection control team at Zawya General Hospital, disagrees. She said that the infection control department in each hospital is responsible for ensuring the safety of all people inside the hospital and protecting them from infection, including the person who washes and shrouds the dead, anyone attending the procedure, and the washing room itself so that it does not turn into a source of infection inside the hospital. 

Mahfouz stressed the importance of protecting the eyes, the nose, and the mouth, explaining that anyone can wash the deceased in the house or at the hospital on the condition that they wear appropriate protective gear, including a face mask, face shield, head cover, gloves and high boots. After finishing, the protective gear should be removed, hands washed thoroughly with soap and water, and the washing room cleaned and disinfected with chlorine. 

“The coronavirus came to teach people about the necessary procedures that have to be followed when washing dead people. So many times when people died and we did not know what they had. Sometimes they had microbes that are way more vicious than COVID-19, and we had no idea,” Mahfouz says.