The deathcare infrastructure, consisting of frontline public servants who handle the recently deceased, faced an enormous strain during the COVID-19 pandemic, as they were required to manage a tremendous number of excess deaths, often exceeding their capacity and resources to do so. Staci Zavatarro, Nathan Fellow at the Rockefeller Institute of Government and Professor of Public Administration at the University of Central Florida, joins the podcast to highlight some of the logistical challenges many coroners and medical examiners faced trying to manage the influx of decedents during the COVID-19 pandemic and the importance of federal and state government policies and investments to improve death care management systems and provide necessary support to the workforce.


Staci Zavatarro, Nathan Fellow, Rockefeller Institute of Government and Professor, University of Central Florida

Learn More:

Last Responders: The Role of Deathcare Systems during COVID-19

  • Transcript

    Transcript was generated using AI software and may contain errors. 

    Alexander Morse  00:04

    Welcome to Policy Outsider presented by the Rockefeller Institute of Government. I’m Alex Morse. While the healthcare infrastructure across the country received significant attention as a result of the COVID 19 pandemic, and rightly so, much less focus has been given to the death care infrastructure. The death care infrastructure, consisting of frontline public servants who handle the recently deceased faced an enormous strain during the COVID 19 pandemic, as they were required to manage a tremendous number of excess deaths, often exceeding their capacity and resources to do so. Staci Zavattaro, Nathan Fellow at the Rockefeller Institute of Government and Professor of Public Administration at the University of Central Florida, joins the podcast to highlight some of the logistical challenges many coroner’s and medical examiners faced trying to manage the influx of decedents during the COVID 19 pandemic, and the importance of federal and state government policies and investments to improve death care management systems and provide necessary support to the workforce. Coming up next.


    Alexander Morse  01:26

    Today, I’m joined by Staci Zavattaro, Nathan Fellow at the Rockefeller Institute of Government and Professor of Public Administration at the University of Central Florida. Stacy, thank you so much for joining today.


    Staci Zavattaro  01:37

    Oh, thank you so much for having me. I’m really excited for this opportunity to talk with you.


    Alexander Morse  01:41

    Sure, we’re excited to have you here too. We know that with your research through the Rockefeller Institute, you’ve looked at death care systems. And I just want to point out that I’ve been following you on Twitter for the last few months. And I know that you visit a lot of cemeteries. And so I wanted to first start off the conversation by asking what got you interested in death care management studies and research and what draws you to cemeteries?


    Staci Zavattaro  02:06

    Yes, I don’t know why. But I’ve always been someone who has been interested in old cemeteries. The running joke with me is wherever I travel, I will find a cemetery. It is inevitable. And I will end up in one. I remember years ago, I was at a conference with one of my doctoral students. And we just needed a walk. And we were in a random spot, random town. We walked by the cemetery. And I said, we’re going in and he said, we’re doing what now? But great. So I don’t know why. But for me, the cemeteries are the best history museum and a place you could visit, there’s so much right there. And these cemeteries are meant for public use there. A lot of them are designed to be public parks, to have you interact with who’s buried there. A lot of cemeteries, depending where you are, and their size, will give you pamphlets or handouts, or as I’ve learned through some of my research about the cemeteries, QR codes, to figure out who’s there. So for me, and if I can’t find that, it’s fun for me to put my imagination to use and wonder what happened to this person who died in 1865. You know, who are you? So that’s been one aspect of my life. And if you go back to after the Pulse shooting in Orlando, that at the time was the worst mass shooting in the country. Myself and three colleagues from the University of Central Florida, were asked to do interviews with folks from the city of Orlando, and two of the people they picked one was the city cemetery manager, and the County Medical Examiner, and hearing their stories, how they dealt with this incident, how they had to help families and all the infrastructure that really was surrounding aspects of how do you handle 49 victims and decedents? It was a way for me to understand that I could combine this, for some, odd love that I have old cemeteries with, there’s an actual public management question here. And what I’ve learned so far is in my discipline, we really don’t think of death management as being a public sector function. So it’s really been interesting for me to talk with those public servants who are doing well, you know, to borrow a term from the management literature, dirty work, and really getting to know how those folks do what they do and why they do what they do. And it’s really been enlightening for me to learn.


    Alexander Morse  04:39

    I’d have never considered a cemetery as a public park before. And it really is also fascinating, the dovetail of a recent unfortunate tragedy, such as the Pulse shooting, or as we’ll get into the tremendous tragedy of COVID-19 and the requirement of public sector workers taking care of decedents. So let’s focus on the COVID 19 pandemic a little bit and its impact on death care systems. What were some of the key challenges faced by these workers and these management systems?


    Staci Zavattaro  05:12

    Yes, that’s really how this next line of my research got started, as we just talked about previously, I was researching public sector cemetery managers, and kind of looking around what was happening in Florida. And obviously seeing pictures all over the media. We all remember them of seeing refrigerator trucks, in some instances, you know, bodies wrapped in cloth stacked on a street. You know, it was this real challenge to both health care and death care systems. So it just prompted a question in me of, well, how are medical examiner’s and coroner’s, specifically that’s how I chose to narrow it because they were so intimately involved in some instances, with you know, handling responding to the pandemic. So as I just mentioned, watching in Florida, what happened there that was intriguing to me, was when the governor declared a state of emergency, it triggered a provision in our law that our medical examiners in, Florida has a medical examiner system, there’s about close to 3000 different death care jurisdictions in different states have different medical examiner’s or corners or a combination, county level state level. It’s very complex, as I’ve learned, so our medical examiner’s were then charged with certifying every emergency related death. Now, if you think about Florida, that’s typically maybe a hurricane. So it kind of happens very fast, and is contained. And as we know, that was not the case for the ongoing pandemic. So the medical examiner system, in addition to our health care systems really got overwhelmed. And this problem was particularly acute, and specifically South Florida, where because of this provision in the law, the medical examiner systems were being backed up and people couldn’t bury their decedents. So eventually, our state’s medical examiner’s and the Commission got together and petitioned to have that part of the law removed. So there’s an actual policy consequence and policy change. So as a scholar of public administration, I’d found that interesting, and I wanted to learn more. So as I spoke with folks in those professions around the country, I heard a lot of those kinds of stories, for instance, Louisiana, relaxing air quality control measures, so more cremation could take place. So again, there’s these these changes to try to handle what I learned and became really familiar with the term excess deaths, meaning more deaths than would be expected. But the case of the pandemic, also meant that as medical examiner’s told me, you know, say is it’s an interesting question of the pandemic. And when medical examiner’s and coroner’s would need to get involved, because technically, the pandemic is a natural death. It is a virus, then the medical examiner coroner system kicks in when there is a suspicious or unknown death. So it was this really tricky policy and implementation question when it came to the virus.


    Alexander Morse  08:28

    It’s fascinating to think about all of the layers in policy decisions in the sector that many people may not be familiar with. Looking at the private sector, how did funeral homes, crematoriums and other related businesses handle the surge in deaths?


    Staci Zavattaro  08:45

    So most of my research is in the public sector. And it gets a little complicated for me, when I am trying to understand what private funeral homes for instance, did. But to the point you just made, they’re part of this sort of ecosystem surrounding deaths. So you had funeral homes, too, that were absolutely overwhelmed. You had the families who had to change the way they commemorate their dead. So there was a lot of cultural competency buried under this, for instance, I’m Jewish, and we have to bury our dead, you know, within, you know, a very short period of time, about 48 hours. And so what happens when you cannot do this? Because what I’ve been kicking around in my head of the bureaucracy of death, this is this, this overwhelming infrastructure that comes in, that families have to deal with and you couple that with laws in different states that, you know, changed, which public sector agency was responsible, it almost made Alex for this perfect storm So that’s why you saw a lot of images of refrigeration trucks backed up, or very popular images of Hart Island in New York. Of these, these essentially mass graves.


    Alexander Morse  10:16

    Yeah, it was a really unfortunate sight. And it impacted a lot of families. And it made it a very challenging time, especially like you mentioned, if you are of a particular religion, and you have some customs that are very important to you. Are there other strains on death care management systems, such as your research mentioned, a lack of forensic pathologists? What is forensic pathology? And why is there a lack? What made this a problem in trying to navigate the COVID 19 pandemic?


    Staci Zavattaro  10:44

    you have forensic pathologist, as I learned are training medical doctors who take extra time to specialize in pathology with an intersection of the law. That’s what forensic is. So they’re the folks who are trained to essentially and I know someone’s gonna probably listen and say there’s so much more, but essentially trained to do autopsy right, and they are medical doctors. Full stop. And that’s some of the differences. In jurisdictions. coroner’s. Again, this is not meant to generalize, depends where you are, your laws are, are traditionally elected officials, medical examiners, traditionally, are these forensic pathologist who are appointed. And that’s sort of the, you know, the difference there. So as I’ve come to learn, in my research, even before the pandemic, this has been an ongoing problem of one, what the medical examiners have told me is finding folks to go into that specialty. Traditionally, it’s a stigma around dealing with dead patients and they are patients, you’re trying to learn what happened. And by and large, every medical examiner, and even coroner, I’ve spoken with said we’re public health agents, our job, in addition to the legal aspects is to really learn from the dead to help the lives of the living. Seatbelt laws are a great example. So even for them, there was a shortage of getting people to go into this position. One, it’s the stigma, perhaps the prestige. You know, some folks have told me that, you know, colleagues in medical school think this is, quote unquote, a not real discipline. I heard a lot about the pay being lower. So it’s, again, this confluence of factors. One of the latest Bureau of Justice Statistics reports from 2018 that is out there that surveys, medical examiner coroner’s offices found there’s about 800, forensic pathologists for the entire country. So how I understand this is there’s, this is my lens now, there’s almost an equity issue, even in death, we talk about health care, equity, and who has access to what services. You flip the coin, it also matters where you die, depending on how big your death care jurisdiction is, what access to resources, there are, what, you know, collaborative and networking relationships, for instance, you know, there are some medical examiner offices run out of universities and they contract with a lot of counties to provide that service. Whereas, you know, Florida has really big counties, and there’s medical examiner’s for each and offices, you know, our all staffed differently, all have different, you know, levels of funding and personnel. So it’s a real challenge. Once you have a medical examiner there, or again, even a coroner, to work with the folks who hold access to the purse strings, to get what you need to make your offices run and what you need outs is a very tough question and depends where you are, who you serve. You know, for instance, when I hear the word mass fatality, you know, and probably most people conjure these really, you know, unfortunate large events as I just mentioned, the Pulse shooting for an example, some jurisdictions, as I learned in my research, if you have the capacity for two decedents in your morgue, three is a mass fatality incident.


    Alexander Morse  14:27

    Wow, what a what a different way to illustrate that and visualize what some of the capacity challenges are for a lot of these jurisdictions. Following up on that your research also highlights the role of technology in the coordination and collaboration between the different stakeholders, whether that’s death care providers, public health agencies, etc. What were some of the specific technological challenges faced by the stakeholders and what did you in your research find that can help smooth out some of these barriers and create better pathways and coordination?


    Staci Zavattaro  14:58

    You know, I think Alex, what was really interesting to me as I did this is, you hear these long term tried and true public management problems, you know, come up even in the realm of death management. And I heard a lot from the medical examiner’s and coroner’s about the technology challenges. One that kept coming up was all these different systems when you think of a state agency, like public health, the medical examiner, coroner’s office itself, the hospital, in Florida, there’s three different state agencies that have some role in, you know, shaping public health. And the problem again, this is not surprising. The problem was the systems don’t talk across each other. So in some instances, I’m thinking of one specific medical examiner with whom I spoke, they said, they realized the systems were not speaking to each other technically, that they started doing data exchange with public health and other state agencies by hand, essentially, this was the height of the pandemic. So that meant gathering on Zoom, and to really drill down into some of the records of what happened, because this matters for what is listed on death certificates, because those vital statistics become data points to inform public health interventions. So if those numbers are incorrect, your intervention could be incorrect.


    Alexander Morse  16:35

    So Staci, I’ve got a bit of a wonky question here, when you send the systems are not speaking to each other? Are we looking at something like data is not input into the relational database? Or is it that the data is coded and formatted differently? So I wouldn’t be able to even read the Department of Health’s data if I had my own, like mental health service data.


    Staci Zavattaro  16:56

    Yeah, thank you for that. This is what happens in my brain, when I know something really well, I sometimes don’t translate it. So thank you for picking me picking me up on that I’ve been working on it for 13 years, I’ve been an academic, it’s the former, it’s really this sort of digital communication between and across systems that I found in my research, is when I say that systems weren’t speaking to each other, that’s what I need, and really being able to share data across these platforms that maybe a hospital uses versus the MEC office.


    Alexander Morse  17:29

    So theoretically, the data is probably formatted, it’s there, it just needs to be linked.


    Staci Zavattaro  17:35

    Correct. And to your point, in some instances, formatted correctly so that these systems talk across each other. And these are big investments of time and money. And as you know, we’re all familiar with, it’s really hard to convince folks who have access to the purse strings in any sort of government agency, that these are worth the investment. So I think when you look at the good faith efforts, among the health care and death, death care practitioners, to really understand what’s going on, in that data by meeting in person or trying to, you know, digitally send data in a different way. It all of these things take time. And so, you know, you asked about kind of, you know, what could we do? And the of course, unpopular answer is invest in technological infrastructure, which also means then you have to take, you have to invest in your human resources and your human capital. And sometimes that means taking folks from what they’re doing to train them on systems. And of course, that makes perfect sense that you wouldn’t do that during the height of a global pandemic, where it was all hands on deck. But there’s really at the core of it, really trying to find a better way for these disparate systems, and disparate input structures to speak together. And if that’s not an option, really trying to learn from the pandemic of, well, when these agencies got together to data share, what worked, what were the barriers, and we still do this, you know, on a digital zoom platform, perhaps or now, if we’re back in person, and we meet in person to talk across, you know, this and it’s it’s time and effort for everybody, but I think well worth the investment.


    Alexander Morse  19:31

    Sure, to your point during the pandemic when a number of stakeholders had to collaborate, forging those connections, it may very well prove to be beneficial, looking forward to help share that information across. Many of us have seen heartbreaking videos and images of those involved in the medical and death care infrastructure. Nurses, Doctors corners, and even family members just burnt out from the stress of handling such such an influx of patients and untimely deaths. Can you tell us a little bit about what that emotional toll looked like? And how the pandemic showcased the need for investment in mental health support?


    Staci Zavattaro  20:10

    That’s a great question. And I think this is where I want to keep going with some of my research, because in my discipline, again, public administration, public management, there’s a good amount of research on mental health for frontline first responders, not so much on these critical last responders, who deal with equally traumatizing things every single day. And what I found Alex, in my research was this really interesting split among the attitudes toward mental health, going back to the Arizona Medical Examiner, in our conversation, they said they hope the pandemic is a watershed, to really have more open conversations about mental health and wellbeing for these death care responders. Because for so long, it’s been, quote, unquote, this is our job, this is what we do. But it also suppresses a lot of the reality that they deal with. So I had a lot of instances of that in my data. You know, for example, one corner in Washington state, they talked about having a contract with a mental health professional who specializes in trauma with first and last responders. So the person has, you know, a better sort of baseline for what these folks are dealing with. So there’s an openness to that there’s a lot of push, as I learned, for more like peer support, to have that support among folks who do this, you can sort of do that critical, quote, unquote, water, you know, water cooler talk, that is actually really beneficial for organizations. The other side, Alex, that I heard was a still a lot of the, we just do what we do. This is not difficult for me, rhetoric. So there’s, there’s almost a split in my data. So it’s going to be really interesting to see if one line of thinking emerges. And couple that, again, with the resource question. It’s a privilege to have on contract, a mental health professional who deals with, you know, trauma, specifically, as we talked about before, if your jurisdiction has capacity for three decedents, there’s also probably not money to have a contract like that. So it’s where do you get the help if you need it? And I think, and I hope one of the benefits? And I’m not sure that’s the right word, I think and I hope one of the potential silver linings of what is an ongoing tragic situation, is more openness to at least have a discussion about mental health, and burnout and care for these, you know, frontline death care workers who are less visible often, but playing this really crucial component in carrying out what is you know, unfortunately, that, you know, the worst day for many people and their families? And how do you deal with that? And how, how do you interact with families to deliver that news in, in some instances, it’s really, it’s really tricky. But it seems from my research that folks, even if their jurisdictions cannot move toward implementing a formal program, that there seems to be at least an openness and a willingness to talk about mental health, and really preserving and appreciating the folks who do you know, death care work.


    Alexander Morse  23:52

    In some of your research, is there anything specific that’s coming out as a state initiative or a federal initiative that can assist with mental health services?


    Staci Zavattaro  24:01

    I came across one in Nevada, that I thought was really interesting. And it started from a first responder, I believe the person was a firefighter. And really looked around and saw the need for more mutual and peer support. So now it’s a formalized, nonprofit network. You know, we all can make donations, and these folks can get together and have, you know, on late medical professionals who could help so I think that’s an interesting model that other states could follow. And it really gets to that sort of collaborative aspect of this, especially for those smaller jurisdictions. And I know there is some work being done at the federal level. There’s a as a group of Death Care professionals at the federal level, who get together more as a meeting group, to say, here’s what’s going on in our particular agencies. And I know there’s a push there for more at least studies about mental health, I’m not quite clear when they will come out. But I know there are some organizations, at least working to get the data to say, we need to understand the foundation of the problem, before we can really do these, you know, targeted solutions. So that’s one aspect, I think, in the interim, you know, it’d be interesting to look at how to do peer support in a way that is beneficial to all because Alex, one of the things I kept hearing was almost a generational divide. That, you know, if you had been in the profession longer, it was we don’t need this, I don’t want to talk to people. And again, I’m let me be clear, I’m not trying to generalize this as everybody, I’m just telling you, what I heard a lot of times, you know, and trying, you know, and, you know, the younger, you know, incoming generation or the newer incoming generation, saying, Well, we talked about this very openly in my school, in my programming. Let’s do this. So it’s trying to bridge some of these. And again, most of what you and I have talked about today, are problems that cut across different agencies, different government, you know, organizations, it’s not only germane to this, but it’s really important when it comes to death care professionals who have chosen to do this hard work that often goes unnoticed until there’s a problem.


    Alexander Morse  26:41

    Based on today’s conversation. It appears the current paradigm may be shifting and providing necessary resources to death care workers will come into focus, Staci Zavattaro. We look forward to learning more as you continue your research. Thank you so much for joining us today.


    Staci Zavattaro  26:57

    Thank you so much for having me. This was a really great conversation. I appreciate your time.


    Alexander Morse  27:04

    Thanks again to Staci Zavattaro Nathan Fellow at the Rockefeller Institute of Government and Professor of Public Administration at the University of Central Florida, to discuss her research on death care management systems and the role of public policy and addressing some of its challenges. You can read more on her research by checking out her blog, “Last Responders: The Role of Deathcare Systems during COVID-19” on our website. If you liked this episode, please rate subscribe and share. It will help others find the podcast and help us deliver the latest in public policy research. All of our episodes are available for free wherever you stream your podcast. Transcripts are available on our website. Special thanks to Rockefeller Institute staff Joel Tirado, Heather Trela, Brian Backstrom, and Laura Schultz for their contributions to this episode. Thanks for listening. I’m Alex Morse. Until next time.


    Alexander Morse  28:15

    Policy Outsider is presented by the Rockefeller Institute of Government, the public policy research arm of the State University of New York. The Institute conducts cutting edge nonpartisan public policy research and analysis to inform lasting solutions to the challenges facing New York state and the nation. Learn more at Rock or by following at Rockefeller inst that Rockefeller i n s t on social media. Have a question comment or idea. Email us at [email protected]

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