Memorialisation during COVID-19: implications for the bereaved, service providers and policy makers

Abstract

Background:

The aim of this rapid perspective review is to capture key changes to memorialisation practices resulting from social distancing rules implemented due to the ongoing COVID-19 pandemic.

Method:

As published peer-reviewed research pertaining to memorialisation practices during the COVID-19 pandemic is lacking, this rapid review includes academic literature from the pre-COVID-19 period and international media reports during the pandemic.

Findings:

Changes to memorialisation practices were under way before COVID-19, as consumer preferences shifted towards secularisation and personalisation of ritual and ceremony. However, several key changes to memorialisation practices connected with body preparation, funerals, cremation, burials and rituals have taken place as a consequence of the COVID-19 pandemic.

Discussion:

Although boundaries between public and private memorialisation practices were already blurred, the COVID-19 pandemic has accelerated this process. Without access to public memorialisation, practices are increasingly private in nature. A number of implications are considered for the bereaved, service providers and policy makers.

Conclusion:

Forms of memorialisation and bereavement support emerging during the pandemic that blend the public and the private are likely to persist in a post-pandemic world.

Introduction

By October 2020, the number of confirmed cases of COVID-19 worldwide passed 41 million, resulting in more than 1.1 million deaths, across 235 countries.¹ In the weeks following the World Health Organization’s (WHO) announcement of a global pandemic on 11 March 2020,² governments around the world imposed measures to minimise the spread of the novel coronavirus through droplet and aerosol transmission.³ Although terminology for these restrictions varies, they will be referred to throughout this article as social distancing rules. These measures are in line with WHO’s recommendations for standard infection control and containment strategies, limiting the gathering of large groups of people and placing restrictions on travel.⁴ It is estimated that unless an effective treatment or vaccine becomes available, prolonged and/or intermittent social distancing may be needed until 2022 or even 2024.⁵

Since COVID-19 was first reported to the WHO by Chinese authorities on 30 December 2020, the social practices surrounding death and the disposal of bodies throughout the world⁶ have been shaped by legal, behavioural and social interventions intended to contain the outbreak.

The aim of this rapid perspective review is to capture the key changes in memorialisation practices that have taken place during the COVID-19 pandemic. Although memorialisation varies across cultures and countries,⁷ it is the immediate and necessary transformation or adaptation of these practices during the COVID-19 pandemic that is the focus of this review which, in the absence of substantial research data, draws upon reports offered by international media outlets.⁸

Method

A rapid review of academic research and international media reports was conducted in line with the practical guide to rapid reviews set out by WHO in 2017.⁹ A search of peer-reviewed literature focused on articles written in English from 2000 onwards, using the search terms ‘memorial’ and ‘memorialisation’, taking into account differences in EN and US spelling. The terms ‘funeral’, ‘burial’, ‘cremation’, ‘ritual’, ‘grief’ and ‘bereavement’ were also utilised.

Given the lack of published peer-reviewed research on the impact of the COVID-19 pandemic on memorialisation practices, the researchers relied upon international media reports to capture attitudes and practices relating to memorialisation. These reports were examined closely and included based upon their credibility, using government or official organisational websites to triangulate the information.

Findings

In attempting to identify key shifts in memorialisation practices due to COVID-19, changes to body preparation, funerals, cremation, burials and rituals during COVID-19 reported by credible international media outlets are compared with pre-COVID-19 memorialisation practices from peer-reviewed literature. Not all shifts are generalisable across countries or cultures, but many shared concerns were gleaned from the firsthand accounts of citizens and service providers.

Memorialisation practices pre-COVID-19

Prior to reviewing media reports of current changes in memorialisation practices, it is worth outlining some pre-COVID-19 studies. Memorialisation has received limited attention in academic research over recent decades, with most studies taking a health services approach to grief and bereavement.¹⁰ Memorialisation practices are more the domain of funeral, cemetery and crematorium service providers, but researchers have now begun exploring links between memorialisation and grief outcomes of the bereaved.^11,12

Changes to memorialisation practices had been evident long before COVID-19,¹³ with the most recent Australian industry report noting that consumers’ preferences were shifting towards higher levels of personalisation and secularisation of rituals and ceremonies.¹⁴ There has also been a shift towards desiring higher levels of engagement by family and friends, often positioned as the community reclaiming death and dying.¹⁵ The use of physical space for memorialisation practices has also undergone changes, with an increase in roadside memorials,¹⁶ the scattering of ashes outside of the cemetery,¹⁷ a preference for cremation over burial due to factors including cost¹⁸ and the lack of burial space in metropolitan cities.¹⁹ At the same time, studies showed digital memorialisation being preferred where the death involved suicide,²⁰ homicide²¹ or the loss of a child.²² This enabled the bereaved to access a site of mourning 24/7 and contact others who had similar experiences.

More generally, the use of online cemeteries, virtual gravesites²³ or memorialised social media pages such as those on Facebook were collectively gaining popularity with those who already use social media in their day-to-day lives,²⁴ enabling them to maintain the presence of the deceased and facilitate an ongoing conversation with them in which others can also participate.²⁵

Memorialisation practices are socially mediated by culture, religion and geographic contexts, but the fundamental ethos of ‘returning to nature’ seems to have survived secularisation.²³ Death as a ‘natural part of life’ is common to the majority of traditions and cultures, which may account for consumers’ increasing interest in natural or green burials as they are also known.²⁶ Key characteristics of natural burials include the use of biodegradable materials, grave markers made of natural materials and soil that facilitates natural decomposition.²⁷ There is a subset of bereaved people who choose not to engage in public memorialisation practices, such as funerals, rejecting the notion that there is a ‘right way’ to grieve and avoiding public scrutiny.²⁸ This view may also be contributing to the increasing demand for ‘cremation-only’ or ‘direct-cremation’ services.¹²

Despite the ‘reclaiming death and dying’ movement, a national survey conducted in Australia showed that funeral providers were perceived as the third most helpful source of support, following that of family and friends, during bereavement.²⁹ This finding was reinforced in another Australian study of funeral providers’ perspectives on improving service outcomes for the bereaved, citing family dysfunction as one of the most common challenges they face in providing support, particularly where family or friends are excluded from memorialisation.¹²

Examples given included separation by distance or divorce and differing views on which memorialisation practices constituted a suitable commemoration of the deceased.¹²

Most recently, a study in the United Kingdom found satisfaction with funeral arrangements to be typically high, recognising that funeral services fulfil multiple functions for bereaved persons.³⁰ There is evidence to suggest that not attending a funeral or a lack of participation in memorialisation practices may lead to poorer grief adjustment and bereavement outcomes, seen in children³¹ not allowed to attend funerals and adults prohibited due to incarceration.³² More research is needed to understand the impact of altered funeral practices during COVID-19 on the mental health and grief experience of those bereaved.³³

Memorialisation practices during COVID-19

Body preparation

During the pandemic, policies for infectious disease control influence the storage and treatment of the bodies across the globe.³⁴ Regardless of the actual cause of death, the bodies of the deceased are subject to common protocols, and change death rituals and customs for all.³⁵ Thus, the preparation of the body by family may have been a key component of collective memorialisation practices,³⁶ but is no longer an option due to the health and safety risks posed by the active COVID-19 pandemic. The washing or dressing of the body as well as placing personal items into coffins has been prohibited by service providers in line with public health legislation.³⁷ Where a public viewing of the body holds importance, an alternative may be encouraging the bereaved to ‘drive by’ to see the deceased one last time with strict social distancing measures in place.³⁸ As the numbers of deaths increase, the storage of bodies has also become an issue across many countries, with public places such as an ice rink in Madrid³⁹ being transformed into a morgue and temporary make-shift options adopted, such as the use of refrigerator trucks stationed outside hospitals in New York.⁴⁰ An excessive number of filled coffins have been stored in churches and hospital chapels, with the need for military army trucks to assist with transportation between venues.³⁷

Funerals

Regardless of country or culture, the ritual of holding a funeral for the deceased has been changed. Most commonly, restrictions have been placed on the number of people allowed to attend the funeral, with a 10 person maximum adopted by Australia, United Kingdom, United States and Brazil.⁴¹ In some cases, this number includes funeral service staff. Deciding who will attend presumably has the potential to increase any pre-existing family dysfunction or conflict.¹² For funeral service providers, the pressure to minimise the number of staff attending funerals means an overhaul of their existing processes and procedures,⁴² while the additional requirements for handling bodies increases demands on the personal protective equipment now required by law.⁴³

Funeral service providers around the world have adopted a number of alternative methods to ensure bereaved families still have an opportunity to participate, through live-streamed ceremonies accessible online⁴⁴ or drive-through funerals where mourners are allowed a few minutes to say their goodbyes to the deceased and where relevant, be blessed by a priest.⁴⁵

In some countries, the option to hold a funeral has been revoked, as China’s National Health Commission issued regulations stating that victims of COVID-19 were to be cremated at the nearest facility, with no farewell ceremonies or other funeral activities involving the corpse to be held and families required to reserve a time slot to pick up the ashes and bury them while accompanied by an official.⁴⁶ In other countries, governments are suggesting families of COVID-19 victims cremate the deceased now and hold a funeral later. An example of the disruption this can cause can be seen in South Korea, where funerals usually take place in hospitals, involving three days of prayer and feasting.⁴⁷ Even where alternatives to funeral attendance have been provided, regulations limiting the number of people in attendance are not appreciated. In Ghana, for example, 25 people are permitted at a private burial, leaving the remaining family and friends to watch the funeral online, described by locals as an ‘unbearable experience’.⁴⁴

It is clear from national and international media reports that major anomalies in funeral practices arise from enforceable social distancing laws. Funeral directors report immense pressure from grieving families to ignore the 10-mourner limit.⁴⁸ In Victoria, where COVID-19 restrictions are currently the most stringent, funeral providers are trying to preserve the ability to hold funerals with the understanding that the absence of such a ritual could hold ‘frightening’ mental health consequences for those left behind.⁴⁸

Cremation

In crematoria in a number of countries the death toll from COVID-19 has created a backlog of bodies,⁴⁹ resulting in families waiting an extended period of time to hold a funeral or memorial service and increased operating hours to meet the increasing demand.⁵⁰ This demand is exacerbated both by families choosing cremation so that they may delay the funeral until social distancing measures are lifted⁵¹ and by some government’s policies that victims of COVID-19 must be cremated.⁴⁶

Burials

The increase in demand for cremation coincides with burial space in existing cemeteries reaching capacity in cities such as New York. There Hart Island serves as a mass burial space for those who died from COVID-19 and have been unclaimed for 14 days.⁵² It is still possible however, for the family of the deceased to request the exhumation and relocation of remains. This contrasts with countries like Iran, where burials according to Islamic rites mean immediate interment, families may have no information about the location of their loved one’s grave and have to hope for this to be communicated to them once the crisis is over.⁵³

Since the COVID-19 pandemic began, the digging of mass graves has been reported in South America, the United Kingdom, the United States and the Middle East, and some media reports include aerial or satellite images of mass burial plots being excavated.⁵⁴ In other places with lower death rates, burials may proceed as usual, except for the limitations on the number of mourners allowed at the gravesite.

Rituals

Many informal memorialisation rituals gather family and friends for mutual support, as in the wake traditionally held after a funeral.⁵⁵ While social distancing restrictions make these rituals almost impossible, mourners are increasingly developing innovative solutions that enable them to share their grief.⁵⁶ One such example in Australia reported that after the online funeral service, the small group who attended the church and cemetery later joined the wider circle of family and friends for a drink over the video conferencing app Zoom.⁵⁶

Although this pandemic-proof method of holding a wake may not appeal to everyone, two grief and bereavement organisations in the United Kingdom⁵⁷ and Australia⁵⁸ have suggested alternatives for memorialisation practices that may have been affected by the social distancing restrictions. In the United Kingdom, Cruse Bereavement Care offers the reminder that memorial events can always be held in the future to say goodbye collectively, have a cup of tea and be able to laugh about memories shared with their loved one.⁵⁹ In Australia, the Australian Centre for Grief and Bereavement places previously peripheral memorial rituals at the centre of funeral participation during COVID-19. Their suggestions include streaming the funeral service online, conducting a personal memorial at home, sending flowers or a sympathy card, signing an online guest book, making a donation in the name of the deceased, writing or recording a message to be read out or played at the funeral and using social media to connect with funeral attendees afterward as a means of social support.⁶⁰ Taking a more inter-disciplinary approach, the ‘Virtual Funeral Collective’ comprises over 70 specialists who work with dying, death and grief on a daily basis, offering a range of COVID-19 resources.⁶¹

Discussion

Most of the articles considering the impact of the pandemic on bereavement tend to focus on what has been lost or taken away – bedside vigils, in-person farewells, preparing the body, eulogising the deceased in funerals that gather their extended social network. Fears are expressed that these absences will result in a higher incidence of prolonged or complicated grief in the years ahead.⁶² The counter to these fears, at least in part, may be the way in which memorialisation practices, already evolving in the years before the pandemic, have expanded to include creative new strategies that for many appear to be viable ways of remembering and grieving their family member or friend at a distance.

One aspect that characterises contemporary society is that boundaries between public and private life continue to shift.⁶³ Memorialisation is already an example of this, as private or individualised ways of memorialising have supplemented, or even in some cases replaced, the public rituals that were normative social practices only a decade or so ago.¹⁰ The COVID-19 pandemic has accelerated these shifts. Boundaries between private and public – home and work, school and work – have been abruptly removed. Private space is now used for what were at the beginning of the year activities primarily undertaken in public spaces. And what had been private activities are now exposed to public surveillance; too many visitors to your home, or travel beyond a restricted zone, may attract attention not only from neighbours but from the police.⁶⁴

As members of societies suddenly subjected to new forms of governance, we have had to find ways to deal with this blurring of boundaries. Many have done so by assuming the changes occupy a brief interlude before returning to the status quo. But as time goes on, it becomes increasingly obvious that this is not the case. At least some of the changes forced upon us by the pandemic will last – the boundaries between public and private life will not ‘snap back’ to where they were in December 2019. Thus, boundaries which were externally maintained by physically moving from one space to another – from home to work, for example – must now be maintained or monitored internally. Daily life requires a different, or complementary, set of skills. Solidarity can no longer be expressed simply by presence at a funeral or an arm around a shoulder: we need to find words or images to offer in its place. Stories that would have been told publicly at funeral services are now retold through videocalls or written up for social media. Without the public component, memorialisation becomes more personal, and connection with others requires more individual initiative. Whether these different ways of remembering and supporting each other will prove to be effective in the longer term depends in part on how capable and comfortable mourners are in exposing their inner reflections to the shared digital world. Even before the pandemic, there was evidence that a number of people were embedding memorialisation in their everyday lives more than in shared public events and static memorials.¹² More recently, online public memorialisation initiatives such as ‘Remember Me 2020’ in the United Kingdom have been established as a collective and public form of memorialisation to honour those who have died as a result of COVID-19.⁶⁵ Clearly, these meet an immediate need during the pandemic. Whether they will persist once traditional funeral gatherings are again permitted, or become a complementary form of memorialisation, remains to be seen.

Recommendations

If new or modified rituals are to fill the gap left by the absence of more traditional rituals that at the moment cannot be enacted, some recommendations can be made for the bereaved, service providers and policy makers.

For the bereaved

It appears that the restrictions placed upon many familiar memorialisation practices have made room for creative new expressions of innovative memorialisation,⁶⁶ and made these new expressions more widely available to serve individuals, families and communities in a post-pandemic future.⁶⁷ While public forms of memorialisation such as funerals and wakes will return, it is also likely that forms of collective action that gather together in digital space, informally or in curated form, a series of individuals’ reflections and tributes will continue. Connection in digital space obviously differs from connection in physical space – but it is still connection, and still provides support.

The distinction between public, collective and individual expressions of grief can be illustrated by changes in physical memorials over recent decades. Commemorating significant losses within a community with statues or sculptures installed with public ceremony in public places continues.⁶⁸ But this public memorial practice has recently been supplemented with smaller and more temporary memorials or shrines established in honour of the deceased at accident or crime scenes.⁶⁹ These informal memorials are collective in the sense that they are contributed to by various individuals, but are not public in the sense of requiring institutional permissions and public ceremony. Collective tributes in digital space take this one step further. It is worth considering what kind of collective memorialisation may be retained or created to represent the collective losses of the COVID-19 pandemic.⁷

For service providers

Although service providers in the funeral, cemetery and crematorium industries have already adapted their offerings to comply with public health legislation and the rapidly changing needs of consumers, it seems likely that further adjustments to service provision will be required in the ‘new normal’ or ‘post-pandemic world’.⁶⁷ Funeral providers were perceived pre-pandemic as among the top three sources of bereavement support, after family and friends.^29,70 This needs to be reviewed in a post-pandemic society to see if bereavement support for those who lost a loved one during COVID-19 shows a different pattern of support.

For policy makers

Concerns have been expressed that the social distancing measures enforced during COVID-19 may place individuals bereaved during this time at a greater risk of prolonged grief disorder.⁶² Already governments have responded to mental health challenges arising from social distancing measures, including increased funding to services and enlisting volunteers to provide informal online support.⁷¹ Bereavement, however, presents specific support issues that are strongly linked with memorialisation.

Conclusion

If, as seems likely, modes of working and learning that blend the public and the private are likely to persist in a post-pandemic world, so too can we expect to see lasting changes to memorialisation and bereavement support. We will need to revive and renew public forms of memorialisation, draw upon the best strategies that have been generated during the pandemic, and seek the advice of those bereaved during the pandemic to ensure that their experiences inform their communities and end-of-life services in particular in integrating the old and the new.⁷² These conversations need to start now so that all participants can focus not only on the problems created by COVID-19 but also the possibilities for building a more compassionate society in the future.