Do not go gentle into that good night,
Old age should burn and rage at close of day;
Rage, rage against the dying of the light.
As his father lay dying, Dylan Thomas urged him to fight death. It was a natural emotion, one that we all feel as, helpless, we watch a loved one approach death. But, when the time comes, many older people embrace death as a relief from the illness that caused it, as a journey into that hoped for good night. Today, as we read the newspaper or listen to the radio, we hear daily of deaths from the COVID-19 pandemic and the cry of the journalists, how many are really occurring? And I ask myself, why do they want to know? Why their morbid interest in numbers?
As John Donne put it:
Each man's death diminishes me,
For I am involved in mankind.
Therefore, send not to know
For whom the bell tolls,
It tolls for thee.
Every death implies sadness for those closely involved, family, friends and carers. But not every death can reasonably be described as a tragedy. All deaths are inevitable at some time and many are expected. Understanding why someone dies is not as simple as it may seem. Our curiosity about causes of death began to be satisfied in the 17th century when Giovani Battista Morgagni In Padua wrote the first great work on pathology, De sedibus et causis morborum
, on the sites and causes of diseases. Since then, doctors have generally considered death and disease to be caused by failure of a vital organ, the heart, lungs, liver, kidney or brain.
In the 1830s, in the dark conditions of the Industrial Revolution, William Parr in London started counting deaths and classifying them according to the diseases that caused them, for the new Register of Births, Marriages and Deaths. Those were the days of pandemics; cholera, tuberculosis, typhoid fever, typhus, syphilis, all subsequently shown to be caused by microbes, but then suspected to be due to miasmas or even God's punishment for sin.
After the discoveries of bacteria late in the 19th century, doctors were able to enlarge their concept of causes of death to include damage to vital organs by microbes, for example to the bowel by cholera, the lung by tuberculosis and the brain or aorta by syphilis. A person might die from heart failure caused by syphilitic disease of the aortic valve in his heart, a woman from diarrhoea from cholera, a child from meningitis caused by tuberculosis.
The need to count and classify causes of death arose from the recognition that an individual's environment is an important factor or determinant of health and longevity leading to an altruistic urge to improve the conditions of the poor and disadvantaged. The strength or weakness of this urge became, often unacknowledged, a defining characteristic of political parties, notably following the observations of Marx and Engels. Many of these pandemic diseases were particularly prevalent and virulent among the poorer members of any society, and this gave rise to the concept of Public Health, originally known as Medical Police.
Ever since the mid-19th century, doctors have been obliged to examine the body of the deceased, if they have not seen them recently during life, before signing a certificate naming the primary cause of death and any supplementary contributing causes. Receipt of this certificate by the Registrar may then lead to an adjustment, making the primary cause consistent with one of the many recognised diseases in an international classification.
Consider two deaths. First, an otherwise fit young man catches the COVID-19 virus from a friend at a party and develops pneumonia which fails to respond to antibiotics and he dies when his heart and lungs fail. His death is attributable to COVID-19 pneumonia, but why did he die when so many others caught the same disease and survived? Was his immune system at fault? And why did he catch COVID-19? Was his friend to blame or his carelessness going out to a party? Even in a straightforward, though in this case tragic example, there is a chain of causation leading to the outcome. The doctor may describe the primary cause of death as influenza, or as pneumonia, or both. If a post mortem examination were to be carried out, the actual cause may either be a bacterial pneumonia complicating COVID-19 or a true viral pneumonia, but short of this, either is possible. Nevertheless, COVID-19 was obviously the primary cause of his demise.
In a second scenario, an 85-year-old lady with advanced Alzheimer's disease, immobile through arthritis and breathless from heart failure, dies after developing a temperature during the COVID-19 epidemic. The doctor will probably record her death as due to the Alzheimer's disease; the viral infection, if that is what it was, was simply the final straw at the end of a long life. But the epidemiologist studying the effects of COVID-19 will notice during the weeks of the epidemic a rise not only in deaths recorded as due to it but also in deaths from all causes. In some, the death was a direct consequence of the infection, in others it was from failure of different organs contributed to by the stress associated with the infection.
In other words, an important part of the toll in lives associated with epidemics occurs in people who are already close to death on account of age and disease. All cause sadness and some are tragic. The tragedy associated with most COVID-19-related deaths has been the isolation of the victim from their relatives, the inability to say goodbye, to give the final embrace to a loved person. The very thought of this is enough to bring tears to one's eyes.
Epidemiologists study deaths, among many other determinants of health and illness, dispassionately as numbers, in the hope that the associations they find may help to prevent them occurring prematurely. Take, for example, the current COVID-19 pandemic as it was affecting Scotland over one week: 4-10 May 2020. Up to that date, 3,213 death certificates in Scotland had mentioned COVID-19. In that week, in total 400 more deaths occurred than the average number over the five previous years, and 383 of these excess deaths were attributed directly to COVID-19. COVID-19 was also mentioned as a contributor in a further 31 cases. Almost all of those dying with COVID-19 had another important pre-existing illness noted as a cause; dementia in 31%, heart disease (13%), lung disease (11%), stroke (4%) or kidney disease (2%). Only 9% had no other cause.
Over all 3,213 deaths in Scotland during the epidemic up till May, old age was the strongest determinant and male gender increased risks by 50%. Ethnic data are not available from death certificates. Most regrettable of all are two stark findings: social deprivation more than doubled the risk and almost half the deaths occurred among residents in care homes. These sorts of data must guide future preventive strategies and act as a rebuke to all UK Governments for the failures of their social policies and for their responses to this pandemic.
In the year I was born, 1938, the average life expectancy of a male child was 64 years. Thanks largely to vaccination, better medical care, and the Welfare State, many like me of that era are still alive, although most have accumulated several near fatal diseases on the way. We are, however, not likely to live much longer; four years being the average. Each time I buy a shirt or pair of shoes, I am aware that the purchase is likely to be my last of that particular item. Nevertheless, medicine has advanced to a point where some doctors regard the death of even such as me, ancient and decrepit, as a failure. When the virus strikes us, they may wish to support our failing lungs, hearts or kidneys, whereas a few years ago we regarded such events as the normal ending of life.
Pneumonia was described by Sir William Osler as 'the friend of the aged'. This modern attitude to preserving life at all costs is enormously expensive and, as we are now seeing, can overload health and social services, sometimes to the detriment of younger people. Happily, there is an alternative: palliative care has now reached the point that we no longer need to fear the act of dying and specialists in this are to be found in intensive care units throughout the NHS. It is an important advance in medicine that older patients entering such units can discuss their options with the doctors early and make rational decisions on their final care. It is, I believe, what most of us would wish. But we must not be deprived of the ability to say goodbye.
One more verse, from Julius Caesar, who you will recall came to a rather unexpected end:
It seems to me most strange that men should fear;
Seeing that death, a necessary end,
Will come when it will come.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own.