National Guard service members decedent recovery and processing operations during the COVID-19 pandemic in New York City

ABSTRACT

In Spring 2020, the New York Army and Air National Guard (NYNG) rapidly deployed to New York City (NYC) to assist in the recovery, processing, and transport of COVID-19 decedents. This study reports on a survey conducted by NYNG service members three to six months post-mission (n = 177). Data showed that there was a dose–response relationship between mission stress exposure and decremented mental health, but certain activities were associated with better mental health outcomes. The paper also reviews resources provided by behavioral health personnel to support service members during the mission and lessons learned to inform future decedent recovery missions.

What is the public significance of this article?—This study highlights the psychological support services and mental health outcomes of National Guard members engaged in handling and processing decedents during the start of the COVID-19 pandemic. Data showed that there was a dose–response relationship between mission stress exposure and decremented mental health, but certain activities were associated with better mental health outcomes.

Introduction

In 2020, the greater New York City (NYC) area became the early epicenter for the COVID-19 pandemic in the United States. A rise in COVID-related deaths in the area and the near shutdown of the city necessitated the deployment of over 400 New York National Guard (NYNG) service members to assist the NYC Office of the City Medical Examiner (OCME) in the retrieval, processing, transportation, and storage of human remains between March 2020 and June 2020. Major General Michael Natali, the NYNG Dual Status Commander in charge of the state’s COVID-19 response, would later predict that the OCME mission would be “historically recognized as the most extensive and prolific domestic military mortuary operation ever seen” (M. Natali, personal communication, March 5, 2021).

The rapid deployment of these service members left little time for training, adjustment to working with human remains, and working in a pandemic impacted area. Regardless of the service members’ lack of experience and minimal mission preparation, military personnel supported city run continuous operations 7 days a week to provide critical assistance. Additionally, individual service members often worked 12-hour shifts to provide adequate coverage to meet the OCME mission demands.

In addition to exposure to human remains, the OCME mission produced several other unique stressors. Several service members tested positive for COVID-19. To limit the virus from spreading throughout the task force, social distancing practices were enforced which limited the opportunity for individuals to engage with peers for support during the mission. Service members who lived in the NYC area were required to stay in local hotels to limit the possibility of COVID-19 infection to and from family members. While the desired intent was to limit exposure and promote mission readiness, it may have indirectly impacted the access to social support. Finally, due to the uniqueness of the early stages of the pandemic and the specific mission, service members were followed by local reporters/photographers who captured their work handling human remains without their consent, which was later included in news stories in print and visual media.

The National Guard

The National Guard is a unique component of the United States armed forces carrying out a dual state-federal commitment, tasked with responding to both domestic emergencies and overseas deployments. National Guardsmen are typically considered part-time service members, with most operating in the traditional duty status of regular monthly weekend drills and a 2- to 3-week annual training. Over 100,000 National Guardsmen were activated in June 2020 alone to support missions both domestically and abroad (Garamone, 2021) and 2020 was the busiest year for the National Guard in activations since World War II (Winkie, 2020).

After the coordinated attacks on the United States that occurred on September 11, 2001, the National Guard were utilized consistently for the wars in Afghanistan and Iraq. Previous studies on the mental health of National Guard troops have been focused on those serving in a warzone while on federal orders (Kline et al., 2010; Shea et al., 2010; Thomas et al., 2010). Studies have shown National Guard troops to have a similar prevalence of mental health disorders as active duty service members when first returning from the deployment but experiencing an increase in mental health disorder rates in subsequent months (Cohen et al., 2015; Han et al., 2014; Milliken et al., 2007). The authors of these studies had theorized that multiple factors may have contributed to these differences for National Guardsmen. These included the loss of health-care services upon redeployment, differences in unit cohesion than active duty units during deployment, and the loss of available social support from unit members as National Guard service members return to their families and civilian communities.

Decedent recovery and mortuary work

Studies on the psychological impact of military mortuary work have focused on military-trained mortuary affairs specialists working in combat zones (Biggs et al., 2016; Flynn et al., 2015; McCarrol et al., 2001; McCarroll et al., 2002). Flynn et al. (2015) showed a high level of anticipatory stress in preparation for working with human remains while also experiencing difficulty with sensory stimuli when actively working with military decedents. Other studies demonstrated that active duty troops exposed to human remains were more likely to display signs of distress and to have higher rates of psychiatric disorders (McCarroll et al., 1993, 1995). These studies have also identified service member preference for utilizing interpersonal support and engagement with healthy coping activities as a way to reduce negative outcomes (Biggs et al., 2016; Flynn et al., 2015). However, no studies to date have analyzed the potential psychological impact of decedent recovery and processing of human remains on military personnel who are largely untrained to do this type of work.

Military behavioral health

The United States military first sent personnel with a focus on military mental health to the frontlines of combat during World War I (Jones, 2006; Warner et al., 2007). Since then, the military has progressively expanded the way mental health is addressed within the armed forces. Uniformed behavioral health personnel consist of psychiatrists, psychiatric nurse practitioners, psychologists, social workers, and enlisted technicians. These personnel are assigned to military treatment facilities, medical companies, combat stress control units, medical command units, and assigned to support brigade-level functions including during both domestic and overseas missions. These professionals perform a wide range of duties including direct treatment of service members, consultation with leaders to promote resilience and health in their units, and provision of mental health and fit-for-duty evaluations (Department of the Army, 2006).

The majority of uniformed behavioral health personnel in the National Guard typically serve as part-time service members, attending monthly drills and being subject to either voluntary or involuntary active mobilizations. Most states have limited behavioral health personnel to support the state’s federal mission to be prepared for prolonged activation. However, the National Guard has assigned behavioral health personnel to accompany service members on recent domestic operations. NYNG behavioral health providers were assigned to the OCME mission to provide direct psychological support to mission assigned personnel. Duties included promotion of positive coping activities within the OCME environment, conducting fitness-for-duty evaluations, leader consultation to reduce unnecessary mission stressors, the development and implementation of a post-mission decompression workshop, and conducting routine follow-ups with the NYNG service members post-mission.

Purpose

Previous studies with a focus on the impact of exposure to human remains during military operations are limited to the study population, setting, and impact of an ongoing pandemic (Biggs et al., 2016; Flynn et al., 2015). Even though the NYNG mobilized the first troops used for missions within this context during the COVID-19 pandemic, other states followed, and as the COVID-19 pandemic endures, and with the uncertainty around future public health concerns, the necessity for service members to engage in missions within this context continues to exist. Findings from a post-mission survey of service members who served on the OCME mission are reported, including the stressors faced by service members specific to this mission, activities the service members found most helpful in alleviating distress, and how these activities associated with overall service member mental health outcomes. This paper also intends to share the behavioral health lessons learned from the OCME mission.

Methods

OCME mission behavioral health initiatives

Due to the circumstances created by the COVID-19 pandemic, on March 23, 2020, the New York City Office of Chief Medical Examiner requested assistance from the New York National Guard in the recovery, processing, and transport of decedents that occurred in private residences, hospitals, and nursing homes. Thirty teams executed mortuary affairs and decedent processing across all five boroughs of New York City continuously (15 teams during the day and 15 teams at night). Through mission completion, a total of 410 NYNG members were deployed in support of the OCME mission over a period of 3 months.

In anticipation of high exposure to traumatic and stressful experiences during the OCME mission, NYNG leadership rapidly deployed behavioral health and chaplaincy to provide direct on-site support to the assigned service members and mission leaders. Altogether, seven National Guard behavioral health providers (five social workers, two psychologists) and two enlisted behavioral health specialists (68X) rotated in and out of the OCME mission, with five behavioral health personnel serving at the peak of the mission.

The behavioral health staff engaged in several initiatives to engage and provide respite to service members. Many of these initiatives were developed in consultation with those outside the OCME mission, including a team of mental health experts from the Department of Veterans Affairs, Office of the Inspector General, and the NYNG full-time behavioral health staff. These individuals conducted literature reviews, provided expert feedback, and supported resources throughout the mission. The consultation calls also provided an outside perspective on issues that providers on the ground may have overlooked.

Knowing that service members exposed to traumatic events have an increased likelihood of experiencing mental health symptoms, the OCME behavioral health team took a proactive approach to increase service member support and exposure to positive activities. Engagement approaches with the NYNG service members included 24/7 behavioral health availability, day and night circulation to the mortuary sites, and participation in decedent recovery operations. Additionally, the team partnered with community members to provide home-cooked meals for the service members, visitation by therapy dogs away from mortuary sites, and acquired U.S. Army Morale, Welfare, and Recreation (MWR) supplies and distraction activities. The team also encouraged unit leaders to monitor service members for possible negative reactions during the mission. Unit leaders were provided handouts on stress reactions and common behaviors to help assist with the monitoring of their subordinates customized for the OCME mission.

Finally, the behavioral health team consulted with NYNG Medical Command to develop and implement a 3-day post-mission decompression workshop for OCME service members. This included addressing both verbal and non-verbal aspects of traumatic stress response, psychoeducation, linkage to available resources, and resilience enhancement activities. The decompression workshops also allowed for additional post-deployment monitoring, individual screening for each service member, connection to a civilian mental health provider and a chance to take a break from ongoing mission responsibilities.

Post-mission survey

Three to 6 months after mission completion, the 410 National Guard servicemembers that deployed to the OCME mission were asked to complete a survey on their experience. The survey was administered using Verint, an online survey tool approved by the U.S. Department of Defense. A screening question was included at the beginning of the survey to assess eligibility. Prospective respondents were allowed to take the full survey to see if they were members of the New York Army National Guard or New York Air National Guard, who spent at least 1 day on the OCME mission. Prospective respondents who indicated that they were either civilians or contractors were screened out and directed to the end of the survey.

Question domains included service member demographics, OCME deployment experiences, unit and leadership support, mental health, family and relationships, and other issues related to the COVID-19 pandemic. Service members were encouraged to complete the survey during a drill weekend but were allowed to complete the survey anytime between September 18 and December 1, 2020. The survey was estimated to take between 20 and 40 minutes to complete and could be completed on any web-enabled device. No incentives were provided for participation.

Of the 410 service members deployed on the OCME mission, 210 respondents initiated the survey. Of those who initiated the survey, 12 did not proceed past the Introduction page, and 21 replied “No” to the following question “Did you serve on the OCME mission doing decedent recovery and processing?” Only 177 met the final inclusion criteria of being either the New York Air National Guard or Army National Guard and assignment to the OCME mission (response rate = 43%).

Measures

Stressful experiences

Respondents were provided with a list of 27 potential stressors that they may have experienced during the OCME mission. The top 10 stressors were used to compute a count score (range: 0–10). Respondents who reported “almost all of the time” or “most of the time” to a given stressor were coded as having experienced that stressor. Respondents who reported “some of the time,” “a few times,” or “almost none of the time” were recoded as not having experienced that stressor.

Helpful activities

Respondents were provided with a list of 18 helpful activities with the question, “During your OCME deployment, how helpful were the following activities to you in dealing with any stress?” Respondents who reported “Very Helpful” or “Moderately Helpful” to a given activity were coded as having found that activity helpful. Respondents who reported “Not very helpful,” “Somewhat Helpful,” or “N/A” to a given activity were coded as having not found that activity helpful. The range for the count variable for helpful activities was 0–18.

Mental health outcomes

The main outcome of interest was any mental health disorder, which was a composite variable of depression, anxiety, and post-traumatic stress disorder (PTSD). Probable depression was measured by the Patient Health Questionnaire-2 (PHQ2; Kroenke et al., 2009; Cronbach’s alpha = .94). Probable anxiety was measured by the Generalized Anxiety Disorder-2 scale (GAD2; Kroenke et al., 2009; Cronbach’s alpha = .92). Probable PTSD was measured by the PTSD Checklist for DSM-5 (Weathers et al., 2013, Cronbach’s alpha = .98). If a respondent met criteria for probable depression, probable anxiety, or probable PTSD, they were coded as having a mental health disorder. If a respondent did not meet criteria for any of these conditions (depression, anxiety, and PTSD), they were coded as not having a mental health disorder.

Statistical analysis

A multivariable logistic regression was used to measure the association between stressors and helpful activities during the OCME deployment and any mental health disorder. The model controlled for demographic covariates including gender, race, and rank group. All analyses were completed using SAS version 9.4 (Cary, NC).

Results

Four hundred and ten National Guard service members were deployed on the OCME mission. The majority of the eligible study participants (n = 177) were Army National Guard (78%), male (82%), minority race (61%), and junior or senior enlisted (82%; Table 1). In addition, 18% screened positive for probable anxiety, 15% screened positive for probable depression, 11% screened positive for probable PTSD, and 25% screened positive for any mental health disorder (anxiety, depression, or PTSD). Approximately 39% of the participants had previous mortuary affairs training versus 61% who had no prior training (data not shown). The average number of days deployed was 54.33 days (Median = 56 days; SD = 26.47 days). In addition, 143 of the 177 respondents participated directly in human remains retrieval or transport.

Table 1.

Demographics and mental health, Office of the Chief Medical Examiner's decedent recovery mission, New York National Guard, March–June 2020 (n = 177).

	n	%
Gender
Female	24	17.78
Male	111	82.22
Race
Minority	76	60.8
White	49	39.2
Rank Group
Junior Enlisted (E1-E4)	55	40.44
Senior Enlisted (E5-E9)	56	41.18
Officer	25	18.38
Affiliation
New York Air National Guard	39	22.41
New York Army National Guard	135	77.59
Probable Anxiety (GAD2)
1-Negative	109	81.95
2-Positive	24	18.05
Probable Depression (PHQ2)
1-Negative	114	85.07
2-Positive	20	14.93
Probable Post-Traumatic Stress Disorder
1-Negative	112	88.89
2-Positive	14	11.11
Any Mental Health Condition (Anxiety, Depression, or PTSD)
1-Negative	95	74.8
2-Positive	32	25.2

The most frequently reported stressor among respondents during the OCME mission was unpleasant smells (71%; Table 2). In addition, respondents reported handling bodies in various stages of decomposition (56%), traveling with human remains in their vehicle (44%), and being exposed to human fluids and/or waste, such as blood and feces (43%).

Table 2.

Top 10 stressors experienced, Office of the Chief Medical Examiner's decedent recovery mission, New York National Guard, March–June 2020 (n = 177).

	Almost all of the time or most of the time		Some of the time, a few times, or almost none of the time
Stressors	n	%	n	%
Unpleasant smells	106	71.14	43	28.87
Working the day shift	85	57.83	62	42.18
Handling bodies in various stages of decomposition	83	56.46	64	43.54
Seeing the personal effects of the deceased (e.g., photos, clothing)	73	49.66	74	50.34
Handling the remains of the elderly	69	47.26	77	52.74
Traveling with human remains in my vehicle	65	44.22	82	55.78
Being exposed to human fluids and/or waste, such as blood and feces	63	42.86	84	57.15
Working the night shift	48	32.21	101	67.79
Fear of catching the virus from the remains	42	28.38	106	71.62
Being in extremely dirty and impoverished environmental conditions	39	26.53	108	73.47

Respondents reported activities that were helpful in dealing with stress during the OCME mission (Table 3). Regarding helpful coping strategies NYNG could utilize in a pandemic environment, respondents reported humor (65%), talking with other service members (65%), talking with family (61%), talking with friends (58%), and talking to people they are close with outside of the military (53%) as being either very or mostly helpful. Additionally, respondents identified listening to music (61%) and exercise (59%) as being very or mostly helpful.

Table 3.

Ratings on the helpfulness of activities, Office of the Chief Medical Examiner's decedent recovery mission, New York National Guard, March–June 2020 (n = 177).

During your OCME deployment, how helpful were the following activities to you in dealing with any stress?	Not very helpful, Somewhat Helpful, or N/A		Very or Moderately Helpful
	n	%	n	%
Recreational activities with other service members	84	60	56	40
Visits from therapy dogs	100	71.94	39	28.06
Humor	49	35	91	65
Talking to people I am close with outside of the military	66	47.14	74	52.86
Talking to other service members	49	35.25	90	64.75
Talking to the chaplain	91	65.47	48	34.53
Talking to the behavioral health personnel	92	66.19	47	33.81
Alone time	61	43.57	79	56.43
Talking with family	54	38.85	85	61.15
Talking with friends	58	41.73	81	58.27
Watching television	79	56.43	61	43.57
Listening to music	54	38.57	86	61.43
Exercising	56	40.58	82	59.42
Walking	63	45	77	55
Playing video games	103	73.57	37	26.43
Doing school work	123	88.49	16	11.51
Going on sightseeing trips	102	73.38	37	26.62
Relaxation exercises (e.g., breathing exercises, meditation)	96	68.57	44	31.43

A binary logistic regression with predictors of gender, race/ethnicity, rank group, and separate scores for stressors (individual stressors shown in Table 2) and helpful activities (individual helpful activities shown in Table 3) was utilized to determine the association with any mental health disorder (depression, anxiety, and PTSD). Overall, the model demonstrated that at least one stressor was significantly associated with any mental health disorder following deployment (Likelihood ratio p-value = .0016). Gender (p = .90), race (p = .20), and rank group (p = .31) were not significantly associated with any mental health disorders during the OCME deployment (Table 4). However, each additional stressor reported was associated with a 27% increased odds of any mental health disorder (adjusted odds ratio (AOR): 1.27; 95% confidence interval (CI): 1.02–1.59). In addition, each helpful activity was associated with a 21% decreased odds of any mental health disorder (AOR: 0.79; 95% CI: 0.69–0.91).

Table 4.

Multiple logistic regression of any mental health disorder (depression, anxiety, and PTSD), Office of the Chief Medical Examiner's decedent recovery mission, New York National Guard, March–June 2020 (n = 177).

	Est	SE	p-value	OR (95% CI)
Male (REF = Female)	0.08	0.65	0.90	1.08 (0.30–3.85)
Minority Race (REF = White Race)	−0.76	0.59	0.20	0.47 (0.15–1.50)
Rank Group (REF = Officer)				p = .31
Junior Enlisted (E1-E4)	0.98	0.87	0.26	2.66 (0.48–14.61)
Senior Enlisted (E5-E9)	0.07	0.84	0.93	1.07 (0.21–5.59)
Score of Stressors*	0.24	0.11	0.0324	1.27 (1.02–1.59)
Score of Helpful Activities	−0.23	0.07	0.001	0.79 (0.69–0.91)

*The top ten stressors were used. Respondents indicating Almost all of the time or Most of the time for a given stressor was coded as one. Respondents indicating Some of the time, A few times, or Almost None of the Time for a given stressor were coded as zero. Therefore, the possible range was 0–10.

Discussion

The National Guard has taken on a variety of missions to provide aid during the COVID-19 pandemic. The NYNG’s OCME mission highlights one of the many occurrences in which National Guardsmen mobilized on short notice to perform disaster response and offer humanitarian assistance. At the inception of the OCME mission, the mission was the first of its kind; the National Guard had never taken on a recovery and decedent processing mission of this size or duration. Since the NYC OCME mission, other states’ National Guard service members have engaged in mortuary-related work at various levels of involvement.

Behavioral health activities and lessons learned

The rapid onset of the COVID-19 pandemic necessitated quick and progressive responses. NYNG leadership was concerned with the potential for negative mental health impacts for service members who were not trained to perform the duties that were to be asked of them and subsequently cope with the high level of negative events that they could potentially experience. In response, trained behavioral health personnel were also rapidly deployed to support a mission with the potential for heavy trauma exposure. Most interventions implemented by the behavioral health team were developed based on prior literature, events that were experienced on the mission, and the availability of resources. Engagement with other mental health providers (consultants) that were not actively on the mission was extremely helpful in creating a proactive response and being able to identify issues past the individual stressors of the day. It is essential to recognize that when serving side-by-side with the assigned service members, the behavioral health team was also exposed to similar stressors and traumas specific to the mission. Consultation was also helpful in providing peer support for those exposures.

Creating a supportive environment during the initial stages of the COVID-19 pandemic, when close interpersonal interactions were limited (social distancing) to decrease the spread of infection, necessitated critical thinking and creativity by the behavioral health team. This included being mindful of ways to engage community resources and leverage available assets of the NYNG. Some of the interventions that received the most positive feedback during the time of delivery were the regular presence of therapy dogs provided by civilian support, the delivery of home-cooked meals to the service members, and the provision of sustenance and personal care items by local groups and the United Service Organizations (USO).

Survey data

The current study is consistent with previous research on U.S. domestic missions where relief workers, especially those working in decedent recovery, report high rates of PTSD and are at high risk of depression and anxiety disorders post-mission (Lopes Cardozo et al., 2012; North et al., 2002). The study also demonstrated that the more stressors that service members are exposed to, the more likely they are to experience negative impacts. Ultimately, this research highlights the elevated mental health risk for service members on humanitarian missions and the need for mitigation measures.

While deployed on the OCME mission, service members engaged in activities to promote self-care and enhance resilience either on their own or with the support of the behavioral health team. The present study found service members who engaged in at least one helpful anti-stress activity during the deployment had lower odds of screening positive for a mental health disorder. Therefore, individual coping strategies, such as journaling, listening to music, exercising, and proper self-care, appear to have lessened the impact of the mission stressors on mental health outcomes. These findings support the importance of healthy coping, and point to the efficacy of work of the behavioral health team.

Recommendations for future missions

There are three main recommendations to support service member well-being for future missions of this type, regardless of country or military affiliation. First, recognize that health protocols developed during a pandemic to limit the spread of disease may also negatively impact the availability of obvious coping activities that service members normally engage in. Service members may have to be coached on how to adapt their engagement with social outlets, such as finding alternative means to utilize positive supports (e.g., use of virtual means of communication or social distancing to speak with friends, family, and fellow service members) or to engage in other activities such as exercise and listening to music for other options for stress relief. The more resources that a service member engages in to cope with mission difficulties, the less likely they are to experience the negative psychological impacts. Second, it is essential for behavioral health personnel to be actively engaged with the service members that are participating in direct work with decedents and encourage engagement in helpful activities when possible. Consistent circulation to worksites and accompaniment of recovery teams during active missions is a key element for building rapport and allows providers to monitor service members for possible stress reactions that may be addressed prior to the development of a mental health disorder. Third, given the staffing and resource limitations during domestic operations, local resources should be utilized to support the military’s mission. National Guard support resources, including behavioral health assets, may be limited due to the normal mission requirements for the National Guard. Community groups can be an important resource for acquiring resources to aid in the support of service members while also providing a positive sign of community appreciation. The availability of community resources should be assessed and included in mission planning.

Limitations

The present study faced several limitations. Specifically, due to the voluntary nature of the study, not every service member assigned to the OCME mission participated in the post-deployment study, which may introduce selection bias. This study was subject to recall bias as we asked participants to answer the survey 3–6 months following their deployment. This was due to the ever-changing conditions dictated by the pandemic, including uncertain redeployment times for participating service members, competing missions for the NYNG related to the COVID-19 pandemic and lastly, uncertainty over the length of the OCME mission. Third, 61% of the respondents who provided an answer for race/ethnicity were racial/ethnic minorities. However, a sizable proportion of the total sample (29%) left this question blank. Therefore, we are unable to determine if the proportion who identified as a racial/ethnic minority was an underestimate or overestimate given the amount of missing data. Finally, this study was limited to only one-time point, and therefore it cannot infer causality or adequately capture the onset of mental health symptoms. Future studies should examine the long-term mental health impact of decedent recovery and processing missions, ideally with data also collected prior to the mission. Future studies would also benefit from examining the development of decompression workshop interventions, prior to the onset of a pandemic-focused mission, to enhance the efficacy of such interventions.

Conclusion

This study provides empirical evidence that negative mental health concerns can be mitigated by service member engagement in positive coping activities. The OCME mission was novel for NYNG service members, requiring many to work long hours doing work for which they had very little experience or training. The mental health burden of this mission on NYNG service members may have been more severe without the resources provided. The development of a proactive behavioral health approach, with the utilization of all available resources, is essential for providing the necessary level of support during pandemic related and other critical non-combat support missions.

Funding Statement

The research was funded by the Military Infectious Disease Program (MIDRP). The authors report there are no competing interests to declare. Materials for this study have been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official policy of the Department of the Army or the Department of Defense. The investigators have adhered to the policies for the protection of human subjects as prescribed in AR 70–25.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability

The data collected belong to the Department of Defense and therefore are not publicly available.