Lawrence County Coroner Scott Norwood is already thinking about what he may have to do if COVID-19 has a severe impact on people in his neck of the woods.

He says he has only had to handle the body of one person in recent days who had flu-like symptoms at the time of death. Lawrence wore personal protection equipment when he did a swab of the person’s nose for coronavirus testing.

“I’m just doing it case-by-case right now,” he said. "I’m erring on the side of caution.”

He’s also concerned about the fact that he has little space available to store corpses.

“I’ve only got the capacity of storing five decedents in my morgue in the hospital, so if we have more than that, I would either have to call the [State Mortuary Operations Response Team] up or get a refrigerated trailer,” he said.

That’s the reality of being coroner of a rural Alabama county during the early days of the disease’s spread across the state.

In New York City, hospitals are resorting to creative methods for handling all the dead bodies.

On Tuesday, the New York Post reported that a makeshift morgue had been set up outside Bellevue Hospital in Manhattan as the city battles the COVID-19 pandemic. On Wednesday, the New York Times reported on what Elmhurst Hospital in Queens is doing to handle its coronavirus dead.

“We had to get a refrigerated truck to store the bodies of patients who are dying,” Colleen Smith, an emergency room doctor at the hospital, told the newspaper.

For many in Alabama today, stories like these may seem like dispatches from an alternate reality or a post-apocalyptic film. But similar scenes may be coming to Alabama. On Wednesday, Gov. Kay Ivey confirmed that the state recorded its first coronavirus death. Since then, the virus has killed at least three more people in three different counties. Many more deaths are expected.

Alabama has been planning for a severe pandemic for years. The Alabama Department of Public Health has published a series of documents over the past 15 years that address how Alabama might handle a surge in dead bodies.

“Alabama will continue to follow its disaster and pandemic planning documents, according each individual respect and dignity,” Dana H. Billingsley, general counsel for the ADPH, wrote in response to an inquiry about what the state plans to do if the number of bodies overwhelms hospitals, coroner’s offices and morgues.

It's a scenario that the department takes seriously enough to include it in the documentation for an "Individual and Family Discussion Exercise" to inform ordinary people about "Personal Pandemic Preparedness" that is posted on its public-facing website.

The document describes a worst-case statewide pandemic in which Alabama hospitals and governments are overtaxed, commerce has ground to a halt and bodies are piling up. The state exercise then poses questions for people to consider before a real-life pandemic strikes.

"If you have family members sick at home and one of them suddenly dies, do you have a plan?" the document asks.

Grim considerations

Public health experts say that Alabama has yet to experience the peak of its COVID-19 outbreak.

But since 2006, the state has been planning for the worst, offering guidance on a wide range of grim considerations that may become necessary during a widespread outbreak. The documents are still posted on the ADPH’s online portals for educating health professionals and members of the public about pandemic preparation and fatality management.

They address the potential that officials and agencies could have to conduct mass burials or mass cremations, temporarily inter bodies to preserve them while cold storage is unavailable, and safely process the corpses of people killed by a deadly communicable virus.

In 2009, the department put on a satellite conference called “Fatality Management During A Pandemic.” A flier for the conference described the importance of planning ahead.

“During a pandemic with mass fatalities, resources that would normally be used to aid in the response will not be available," the flier said. "The usual process of handling the dead could be significantly altered.”

That same year, an ADPH training led by Bill Harris, president of the Alabama Coroners Association, cited the "need for each Coroner to seriously consider how a pandemic will affect their county and how they will respond."

Harris called on coroners to consider how they would handle a situation in which “decedent [corpse] pick up may not be timely,” according to his presentation materials. “Who will be available to pick up decedents? Where will decedents be taken if funeral homes are at capacity?”

Coroners need to think about how to manage "cold storage or lack there of (sic), decedent identification, decedent tracking, personal effects" and other tasks during a pandemic, the training materials state.

And they even need to consider “mass burial planning” logistics including “trigger, location, security, interment and disinterment, decedent tracking and identification,” according to Harris’ presentation.

Also available on the ADPH website is a "Fatality Management Toolkit" that was compiled by the ADPH, Alabama Center for Emergency Preparedness, Alabama Department of Forensic Sciences, and the Alabama Coroners Association and distributed to coroners and medical examiners in 2009.

It includes a 2006 white paper by the Cremation Association of North America about what state and local officials should expect during a deadly nationwide pandemic.

Coroners should anticipate having insufficient cold storage, which could require them “to use non-traditional methods of temporary storage, such as temporary internment” of dead bodies, according to the paper.

Another document in the state toolkit, the "Medical Examiner/Coroner’s Guide For Contaminated Deceased Body Management," was published in 2006 by the National Association of Medical Examiners.

It advises coroners that "[i]t may be necessary to inter bodies temporarily to preserve them … In other instances, it may be necessary to have a mass interment (or cremation) that is essentially permanent."

County coroners

Norwood, the coroner of Lawrence County in north Alabama, says he is coordinating with the county’s Emergency Management Agency and local officials to ensure that he is as prepared as possible for what’s yet to come.

“I’ve been in three briefings with the county EMA and county officials about COVID-19,” he said.

That type of community planning is essential, according to the ADPH's 2009 "Fatality Management During A Pandemic" training flier:

"Local, comprehensive fatality management plans are needed in order to deal with the large number of decedents that could occur as a result of a pandemic."

In Colbert County, Coroner Justin Gasque says he hopes the virus won't take too heavy a toll on the more than 50,000 residents of his county.

“Hopefully it won’t get that bad. Everyone’s staying in, doing what they’re supposed to,” he said. “I feel like we can handle it, unless there’s a lot of deaths coming that we can’t foresee.”

If his office does get overwhelmed with bodies, Gasque says he is confident that he will be able to get enough outside support to deal with the surge.

"If we get in a position that it's something we can't handle at the coroner's office, we can go to the EMA and then there's the SMORT team," he said. "If I have several deaths here, whether it's pandemic-related or something like tornadoes, we can call them in to assist."

SMORT team

Doug Williams, commander of Alabama’s State Mortuary Operations Response Team, often referred to as the SMORT team, is a funeral director and embalmer who owns a handful of funeral homes and cemeteries and a crematorium in Cullman County. He is not as bullish about the concept that his team will be able to effectively fill the gap if county coroner’s offices become inundated with the bodies of people killed by COVID-19.

"Our team is mostly made up of funeral directors, embalmers and coroners from across the state, and if we have a statewide incident where people are dead across the state because of this virus, we are all going to be [in our home counties] working," he said.

He explained that the team is more of a strike force that is called in for assistance when a localized mass casualty incident takes place in Alabama. For instance, last March, the team was instrumental in helping to handle the dead following a tornado in Lee County that killed 23 people and overwhelmed the four-person county coroner's office.

"The SMORT team is not really set up for something statewide like that. In the coronavirus situation, where there's just going to be deaths sporadically everywhere, I don’t see us responding," Williams said.

The ADPH included a similar assessment in a 2011 hazard assessment report that states that "outside resources would not be available" to counties during a severe statewide pandemic.

But Williams said his squad has the ability to provide limited additional resources as needed. The team can deploy three mortuary units – Williams described them as mobile autopsy suites – as well as eleven refrigerated trailers that can each store between 18 and 28 bodies on morgue-style racks.

"If a morgue was to get overwhelmed, we'd be able to help them do cold storage until they can get the bodies processed. But as far as the team itself, I don’t see us going to one place in particular unless someplace like Jefferson County has just a massive amount of bodies at one time," he said.

"But I think it's going to be people dying slowly, unfortunately, and it should be able to be handled at the county level."

Emergency Management Agencies

County Emergency Management Agencies are the other key stopgaps coroner's offices can turn to for assistance during major health crises.

As of 2017, only 63 percent of hospitals were "planning with the local EMA and coroner for Mass Fatality Management," according to an ADPH study published in March 2018. But coroners and officials said in interviews that coordination and preparation efforts have quickly ramped up since the coronavirus threat has emerged.

The ADPH detailed what county EMAs should include in their mass casualty plans in a template published in 2008 that is still featured on the portion of the department's website dedicated to "Fatality Management During A Pandemic and Other Emergency Events."

The template calls on county EMAs to identify local partners who will play a role in mass casualty incident response, compile information about available cold and non-cold temporary storage facilities, "[i]dentify potential local transportation to pick up [corpses] from home[s] and other collection points," and more.

In Jefferson County – home to Birmingham which is currently under a shelter-in-place order to help slow the spread of COVID-19 – the county EMA is working with other agencies to ensure that coroners and other public health officials have the resources they need to handle large numbers of casualties, according to Melissa Sizemore, emergency management officer for the Jefferson County EMA.

She pointed to the efforts of the Jefferson County Healthcare Coalition, comprised of the county's EMA, its department of health and its coroner/medical examiner's office.

"The Jefferson County Healthcare Coalition regularly prepares to coordinate the response to mass fatality events," Sizemore said in an email. "In response to COVID-19, the responsible agencies have contingency plans in place and are prepared to respond as required."

In Etowah County, the county EMA has been interfacing with the county’s sheriff’s office, coroner’s office and other relevant agencies over coronavirus preparations for weeks, according to Sheriff Jonathon Horton.

“I’ve had emails and things of that nature every day or every other day with our EMA. We’ve had meetings among elected officials,” Horton said earlier this month. “We’ve come up with a continuous operation plan: if this person gets sick, who takes over, who takes over, who takes over, three deep.”