Global health loves death. We deify mortality. We revel in human oblivion and its causes. We count, estimate, and monitor obsessively the casualties of disease. But there is one quality that global health does not bring to death. We don't value the end of life. Such indifference is strange. As Shahaduz Zaman (University of Sussex) argued last week, “We all die, so let's talk about it.” He was speaking at our Global Health Lab, held at the London School of Hygiene & Tropical Medicine (LSHTM). Death has a universal incidence. Yet we seem content to allow appalling global disparities in death, dying, and end-of-life care. We can change this pattern of neglect. Universal health coverage could be a lever to ensure equity. There are two narratives. The standard model is institutionalised specialist palliative care service delivery. An alternative is a more generalist community approach. Zaman gave examples of neighbourhood networks of palliative care in India and Bangladesh. Here, end-of-life care is delivered in the community by palliative care assistants or volunteers. But the gold standard is held to be western specialist care. The UK does well by this measure, topping global indices of Quality of Death. But what a paradox. While the UK is regarded by others as an ideal place to die, there is concern and disagreement about how well palliative care is delivered. The Liverpool Care Pathway was withdrawn in 2014. Most British people do not die in their preferred place (home). And criticism about the over-medicalisation of palliative care is growing. Zaman argues that it is time to re-evaluate the idea of a good death. “The body of the dying person becomes an arena for conflicting (sub)-cultures of providers, policy makers, and relatives.” Uncritically transposing models of palliative care from one culture to another is dangerous. Instead, global health should encourage plurality in how we address dying. One should identify “‘the particular’ within ‘the universal’ at the end of life”.

Copyright © 2019 Richard Horton

Copyright © 2019 Richard Horton

Simon Cohn (LSHTM) was interested in dying, not death. Dying is dynamic. People are dying at older ages, over longer periods of time, and with more complex comorbidities. Dying is, in his view, approaching a crisis, one that embraces the whole of society. Global health is “an implicit kind of violence” because of its reductive focus on numbers. Dying is part of the process of living. It is contestable. Where does death occur? In the body, the person, or socially? Why does death occur? Because of our values, our morals, or our beliefs? Indeed, if death occurs at all. Who is for reincarnation? Death isn't only biological. And dying doesn't happen only to the individual. Today, biomedicine frames end-of-life care as the antithesis of medical practice. Modern medicine is about aggressive treatment with the goal of life. End-of-life care is about resignation, failure, decline, and deterioration. Global health should see palliative care not only as an urgent imperative but also as a means to disrupt our very notions of care. Irene Higginson set up the world's first purpose-built institute of palliative care—the Cicely Saunders Institute—at King's College London. Palliative care remains pitifully low on the global health agenda. Reasons go beyond the privileging of cure over care. Some think the end of life can be managed by ever-better algorithms. Others try to describe ever more precisely the problem of palliative care instead of trying to solve it. While still others ignore the fact that less than 0·15% of research funding is dedicated to palliative care. Policies for end-of-life care are lacking. Education is sparse. Non-pharmacological treatments are few. And palliative care expertise is thin. What we need is a new movement for healthy dying.

Copyright © 2019 Richard Horton

Maybe palliative care's challenge goes deeper. Attendance at our Global Health Labs is usually high—commonly in the hundreds. But only 40 people attended our discussion about death. Why? Was it some kind of discomfort with the idea of death? Terror about the notion of losing independence and autonomy? We don't know. What we do know is that death is more than a table of numbers in a research paper. Death and dying are the supreme affirmations of human life. Global health should accord them both the respect they deserve.

Copyright © 2019 Richard Horton