As of July 2023, more than 1.1 million Americans have died from COVID-19, and while the pandemic has had enormous social, economic, and psychological consequences for Americans, it has also had an impact on the backline public servants who dedicate themselves to death management such as coroners and medical examiners. In new research based on interviews with deathcare workers, Staci M. Zavattaro looks at the challenges that these professionals have faced during COVID-19 including difficulties in counting pandemic-related deaths, new safety procedures and the mental health effects of the pandemic.

I listen and type notes furiously as a coroner in a medium-sized Louisiana parish explains his role as a public servant. My recorder is also rolling along as my fingers fly across the keyboard. I stop when I hear barking. Is that coming from outside my window? No. It’s coming from outside his. The sound momentarily takes me out of focus.

“I was a police officer. I was a doctor and a cop,” he says, stopping to apologize. “The office dog is barking at somebody out the window.”

It was a brief moment but a reminder of the humanity surrounding public servants who dedicate themselves to death management. Unfortunately, the still ongoing COVID-19 global pandemic brought the world face to face with death – images of mass burials in Hart Island in New York, morgue trucks to relieve body storage overflow, and truncated burial rituals thanks to social distancing rules in place at the time.

The effects of COVID-19 on death workers

This brought me to my research question: how is the ongoing COVID-19 pandemic affecting medical examiners and coroners? There was a lot of media coverage – necessarily, I should note – about frontline healthcare workers, yet deathcare workers were often absent from this reporting and even the research in my field of public administration. My recent work attempts to shed light on some of the core issues facing some medical examiners and coroners during the pandemic.

To be clear, my findings are not meant to generalize to the myriad deathcare jurisdictions and systems throughout the US. My aim was to speak with these crucial public servants whose job is at once to serve the living by learning from the deceased as vital public health agents, as well as the dead by carrying out an impartial investigation guided by science and principles rather than politics and pandering.

The complexity of counting COVID-19 deaths

After analyzing my interview data from 18 medical examiners and coroners throughout the country, three patterns stood out. First, counting pandemic-related deaths proved tricky, especially as healthcare and deathcare systems became massively overwhelmed. Indeed, counting COVID-19 deaths is complex, and as one medical examiner from a large Florida county said to me: “Are we trying to figure out if people are dying with COVID or of COVID? So, if someone was shot, I don’t really care if they have COVID.”

The problem came when deciding how to fill out a death certificate, which itself is not an easy task given there is no formal training for physicians on how to do so. As one medical examiner in another large Florida county explained regarding the complexities of marking death certificates, “Don’t put respiratory failure on [a death certificate] as the cause of death. If it was stand alone, you could put that on every single death certificate the day were born. It’s a true statement that adds zero value. It has no meat. It’s just a physiological staple common in all deaths. Dead people don’t have a heartbeat or lung functions.”

What is for certain: the COVID-19 deaths in the US continue to defy accurate counting, and my research supports this claim. As my research indicates, this means public health data are also not accurate, meaning other public health administrators cannot use the data to find interventions. This counting is vital for other public health concerns such as the ongoing opioid epidemic in the US. As a coroner in Ohio explained, “Every overdose death gets a ZIP [code] and address so there’s better mapping for intervention. Now the state gets numbers right away so it can deploy rapid intervention teams. They go to these communities with their drug support officers” to do targeted interventions. Deathcare workers, then, are impacting lives by using data from the dead.

“COVID-19 Memorial Field of White Flags o” (CC BY 2.0) by Amaury Laporte

COVID-19 has meant new safety procedures for death workers

Second, my research shows that offices had to alter procedures during the pandemic to ensure the safety of their employees and the public. For instance, one medical examiner and one coroner mentioned altering autopsy procedures to eliminate one of the most dangerous aspects: opening a skull. Said the coroner in Ohio: “The saw is the most dangerous… It’s not cutting, it’s beating so it makes aerosols, so COVID could be spread that way by… putting dust in the air and breathing in infectious particles.”

Still, other offices had to make policy changes to ensure enough personnel were in the building, that each death investigator and autopsy specialist had access to proper personal protective equipment (PPE), and that enough testing swabs existed to use on cadavers. One major change was related to storage for the dead, with many morgue facilities getting overwhelmed and refrigeration trucks in short supply. Explained a medical examiner in a large Arizona county: “We expanded cooler capacity by reconfiguring storage racks in existing coolers… It was kind of a rinse and repeat of that.”

The mental health effects of a global pandemic

Finally, respondents to my interviews indicated mental health concerns and fatigue associated with dealing with an ongoing global mass fatality incident coupled with a normal caseload of suspicious deaths. Post-traumatic stress disorder is a real concern for last responders dealing with death daily. Said a chief medical examiner from Connecticut: “I think all of our offices in a way burned out. The investigators are overworked. We are short-staffed. We have more and more work to do.” Though, there is still seemingly stigma about seeking help within this profession.

A coroner from Indiana explained: “You’re calloused to it. You really are… I’m not saying all death is not sad, but you know when you lose an infant to unsafe sleeping conditions or something like that, that’s sad. That’s preventable, and that does affect me because I’ve got kids and grandkids and all that. It [COVID-19] was just business as normal for me and all of our people. We had a job to do, and we did it.”

In sum, deathcare workers in the public sector are playing a crucial role in public health yet face barriers when it comes to being able to do their work with appropriate resources, staffing, access to technology, and proper networking and planning. Moreover, these workers face a stigma every day as their jobs are perceived as “dirty work,” to borrow a term from management research that means work seen as physically disgusting or tainted. Despite this perception, medical examiners and coroners remain important public health agents using evidence and data to intersect medicine and the law.

The coroner from Louisiana, with the barking dog, reminds us of this duty to serve: “As a physician, that’s what I do for a living is I take care of people. As an ER doctor, I am given the opportunity with this job [of coroner] to take care of folks at sometimes the worst possible moments of their lives. Nobody comes to the coroner’s office for anything happy.”

• This article is based on the paper, ‘Death managers, public health, and COVID-19: An exploratory study’ in Public Administration Review. 
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• Note: This article gives the views of the author, and not the position of USAPP – American Politics and Policy, nor the London School of Economics. 
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