Heroes Not Zombies

Let’s talk about death.
Because we don’t.
Somehow it’s not acceptable to talk about death, almost as if it’s bad manners, or maybe just that you’re going to make someone uncomfortable by talking about it because death is something we all hope to avoid. Today, anyway! Maybe we think that if we don’t talk about it, don’t even think about it, then it won’t happen. Which is equivalent to a child covering their eyes to hide and thinking nobody can see them.
Death is certain. It’s inevitable, inescapable, unavoidable.
Yes, yes, I know that, but let’s deal with it when it comes along, and, look, it’s not coming any time soon, right?
I don’t have the impression that death is difficult for the dead, but, then, what do I know? I’ve never talked to a dead person. Or, more accurately, no dead people have ever talked to me.
Dying, on the other hand, can be really difficult. I’ve seen difficult deaths, been present through those final weeks, days, minutes of final struggle. Some of those deaths make the moment of death like a release, a final end to suffering.
And death is difficult for the living. It’s loss, emptiness, sadness, distress, grief….It changes the lives of the living permanently. Life is not the same after death.
But life is never the same anyway. Life is a process of constant change. Even in the midst of our most fixed habits and routines, life changes. Relationships are formed, relationships fall apart, new jobs appear, old jobs go, people enter our lives, and they leave, some temporarily, some permanently. Isn’t death just one of those changes? A kind of ultimate experience of transience?
How many deaths have you witnessed?
I’ll never forget the first time I had to certify someone as dead. As a Junior Doctor working in a hospital, one of my responsibilities was to confirm that a patient had died, and initiate the formal recognition of their death, writing in their case file “Time of death” and entering the time I declared it. The first time for me I was called, as on call doctor, at about 3am, to a ward I’d never visited before. An elderly patient there, whose death was expected, had just died. It was my responsibility to examine him for signs of life. I took my time. I didn’t want to get it wrong! I listened to his chest for a long time, but couldn’t hear any heart beats. I tested for various reflexes and got not response. I stared long and hard into his eyes, using a device called an ophthalmoscope, shining a light onto his retinae to look for the signs of death I’d been trained to see. Finally, I was convinced. Looked at my watch, and retired to the little office at the end of the ward to write the formal statement of my examination and the date and time of his death. As I walked back along the empty main corridor I began to think about what I’d just experienced. I wondered whether or not it was true that we each have a soul, and whether or not that soul hovers around the body for a little time after death, before departing. I wondered if the man’s soul had been hovering around behind me, as I checked his body for signs of life. I wondered if his soul might have started to follow me from the bedside to the office, and maybe, now, as I walked down this empty corridor. I started to walk faster and wondered whether or not a soul could keep pace with a living person. My heart started to beat faster and as I turned into the on call rooms corridor to go to bed I flicked on the light switch in the stair well and “bang!” the light bulb flashed on then immediately went out again. Well, that spooked me! I ran up the dark stairs taking two or three steps at a time, fumbled as I tried to get my key into the on call room door, eventually managing, throwing the door open wide, then slamming it hard behind me. As I stood, breathing heavily, with my back to the door, I suddenly thought. “Hey, surely ghosts can walk through walls!” At that point I realised how absurd it was to be imagining such things. Took me a while to settle though!
I’ve seen many deaths since then. I don’t think it ever became routine. I didn’t imagine souls hovering around me any more, but I always found the experience disturbing. Maybe that’s just normal.
For most of us we won’t have experienced many deaths directly. When they happen, they are significant events. They feel like something has gone wrong. Maybe somebody is to blame. Maybe someone has failed. Maybe we even feel the dead person has failed….failed to rage against the dying of the light.
When you talk to people who have had an encounter with death, a near miss, a sudden, or unexpected one, brought on by an accident or an illness, it’s not uncommon that they will say it’s made them realise how precious life is, how fragile, how maybe until that moment they hadn’t really known that. Well, known it as a sort of fact, but not known it as a person. There’s a difference. Maybe they’ll say they’d have a wake up call. A wake up call to what? To the knowledge of the shortness of life. They might say it’s made them realise that if they want to make the most of life, then it might be a good idea to start now.
Or they might have a heightened sense of reality, of the unpredictability of life, or even of the inevitability of its ending.
Thinking about death because you’ve survived a serious accident, recovered from a serious illness, or have just experienced the death of a loved one, a friend, or a colleague, can make you re-evaluate your life.
Re-value your life.
Feel how precious and fragile it is and decide to make some changes, to stop procrastinating, to stop living this way in the hope that one day, in the distant future, you’ll be able to live a different way.
That’s the gift of death. The gift of life.
Do we have to go through such an experience to get there? Can we only wake up, reassess our choices and values by having personal encounters with death? Or can we make such decisions, initiate such changes, by thinking about death, or talking about it?
If you knew you had one year left to live, what would you do differently?
Stephen Levine, who passed away in January, 2016, wrote a best selling book entitled “A Year to Live” where he describes the process of living as if you have only one year left. Many people have followed his programme since.
But the whole idea of thinking about death as a way to a better, or should I say, more considered, life, goes all the way back to Socrates (there are whole schools of thought on this subject from many other cultures too)

In the Phaedo Plato has Socrates claim that in death the soul is released from the impure and contaminated body, and thus becomes able to attain pure knowledge of Truth. In the dialogue Socrates says: “It really has been shown to us that, if we are ever to have pure knowledge, we must escape from the body and observe things in themselves with the soul by itself. It seems likely that we shall, only then, when we are dead, attain that which we desire and of which we claim to be lovers, namely, wisdom…”
Thus according to Plato upon death the philosopher achieves that which he has been striving for his entire life. Because of this Plato has Socrates claim that the practice of philosophy in life is really a dress rehearsal for what comes in death: “…those who practice philosophy in the right way are in training for dying, and they fear death least of all men.”
Since the time of Socrates and Plato philosophy has assisted countless individuals confront their own mortality, and provided consolation in the face of what many consider the greatest of all evils – death.

A related train of thought is wondering what you would do differently if somebody you knew had only a year left to live. What if that somebody was your mum or dad, a brother or sister, a lover, partner or friend?
And what if it wasn’t a year? What if it was five years, or, ten? Would that change anything? Would either of those scenarios lead to different choices?
So, a little contemplation on death from time to time, might have a serious impact on both the way we live, and the way we are with others.
You know, I think there’s an awful lot more we could consider down this road, but maybe that’s enough for now.
Before I finish, though, when I was researching life expectancy figures for the articles I was writing about health, I discovered that a male Scot aged 65 (that’ll be me in a few months time!) has a life expectancy of a further 19. 7 years. When I read that I had mixed feelings. I mean twenty years seems quite a long time, right? But on the other hand, it feels as almost no time at all! But what I realised I was doing with that figure was considering it as an end point. I thought, well I might just see the start of 2040 then! But then I read what “life expectancy” is. It’s a median. That means that in 19.7 years time, 50% of male Scots, aged 65 today, will be have died. But 50% will live beyond that timescale. It’s not an end point. It’s the 50/50 point!
Hey, how human is it to grasp at offer of hope?! (Well, that’s another subject to consider….the importance of hope)
OK, this is like a PPS but I must tell you about the patient I saw one day. I knew her from previous visits, but this day she seemed particularly out of sorts. I asked her what was bothering her and she said “My husband’s been diagnosed with cancer. He’s been told he’s got six months to live”
I sympathised with her and asked how that news had made her feel. Her reply took me completely by surprise.
“I’m angry. Really angry. I mean how come he gets to know how long he’s got and I don’t get to know how long I’ve got?!”
We had an interesting conversation about uncertainty after that!

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How do you have a healthy population of human beings without a healthy environment? Isn’t it pretty obvious the two issues are linked? Because there are no human beings who live outside of the environment. You could even say that it’s a false distinction. There is no “us” here, and an “environment” over there. It’s not like the environment is a foreign country you can visit with a tourist visa.
But what do I mean by environment? I often find I’m tempted to write environment in the plural, to talk about “environments” rather than a singular object called “THE environment. Because the environment is just the circumstances in which we live. It’s that vast web of connections which weaves every single individual into the whole.
There’s a physical environment of earth, air, water and fire. There are the cyclical environments of energy, of heat, cold, wind and rain.
There are the geographic environments of place. There’s a long running French TV series called “Rendez vous au terre inconnu” (Meeting in unknown places), where someone spends two weeks with a remote tribe and a camera crew capture the experience. I love it. It’s done with great sensitivity and compassion. Every episode opens your eyes to other ways of living and it is frequently surprisingly moving. It’s very human. In one episode they did return visits to three places and showed each group the original films of both their own place and the places of the other two. One group lived high in the mountains, one in a region of permanent snow and ice, and a third on houses built on poles in the sea. It was startling to see such diversity and to see each group express their astonishment that other people could choose to live so differently. There’s no doubt that the physical places where we live influence our daily habits, our diets, our whole outlook and our patterns of disease and health.
City dwellers face different challenges from rural ones. Coastal communities different ones from desert dwellers. And so on.
But there are other, less visible, environments. Our social environment of family, friends, colleagues and neighbours. Our cultural environment of values, practices and beliefs. Our political environment of laws, limits and agreements. And so on.
We live embedded in all of these and more. We are influenced by them, and we influence them.

 
In the books as “Linked”, by Barabasi, “Connected”, by Christakis, “The Bond”, by Lynne McTaggart, and “The God Problem”, by Bloom, we can see how we live in networks of relationships which influence everything from or chances of becoming obese, or catching certain infections, to the daily choices we make. We are not as “individual” and separate as we think we are.
Look how “memes” spread, how videos become “viral”, how quickly behaviours and attitudes spread across cultural and physical borders through social media.
If we want to create healthier populations we have to address these environments.
I was going to write about things like the number of industrial chemicals which can be detected in the blood of new born babies in Paris, or the insecticides, fertilisers, herbicides present in everyone’s urine, or the number of prescription drugs which are present in our drinking water, or the amount of plastic washing up on remote islands, or even the estimated 400,000+ people who die every year in Europe from disease caused by air pollution.
But I’m not going to.

You can read any of these kinds of details any time. If those sorts of stories don’t appear in your newsfeeds, you can search for them online. They really are not hard to find.
No, the only point I want to make here is that we do not live separate lives, so if we want to create healthier societies we need to pay attention to our multiple environments. We need to understand them better, then make some different choices. Together.

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This is one in a series of articles about health. There’s an almost unspoken belief that the way to make people healthier is through Medicine, and the Health Services through which Medicine is delivered. I’m not sure that’s true. Some of the most striking improvements in population health throughout history have come through the provision of clean water, effective sewage systems, and making such changes as housing the population in better houses, reducing malnutrition, and tackling poverty.
I think it’s important to deliver good health care, and, for me, that means both adequately resourced health care, and, perhaps more importantly, human-scale health care.
What do I mean by that?
Health care where the day to day, hour by hour, minute by minute focus is what human beings do together. It’s caring, compassionate, staff who are well educated in engaged and committed relationships with those who are suffering.
But one thing is clear. The demand for health care is increasing, and shows no sign of tailing off. The higher demands rushing fast down the pipeline come from demographic change with many more people reaching old age, and, consequently, many more with chronic illnesses, complex needs and, ultimately a requirement for good, end of life care before they die.
If we want to tackle the rising demand, we have to deal with the causes of ill health, and if we restrict our focus to individual behaviours, we’re going to fail. We have to deal with the economic, social, and environmental causes of ill health if we want people to live more of their lives in good health.
I’ve written about housing and food so far, and here I’d like to explore education.
Some people claim that education is THE most powerful way to make an impact on population health and it’s a hard claim to refute. Education can improve health in many, many ways, some more obvious than others.
For example, education can reduce poverty and improve incomes, enabling people to find more adequate shelter and to eat more nourishing diets. Education is particularly effective when focused on women and girls. Educated girls and women tend to be healthier, have fewer children, earn more income and provide better health care for themselves and their future children. It reduces maternal deaths and helps to combat infectious diseases, including HIV and AIDS.
Did you know that a child whose mother can read is 50% more likely to live past the age of five?

Don’t you think that’s stunning?
If you want to explore this further have a look at the United Nations 17 Sustainable Development Goals.
But there is another aspect to education I’d also like to consider. It’s the education embedded in the ordinary doctor-patient consultation. Or at least, it could be. One of the first tasks of a doctor is to make a diagnosis, which is a way of saying to arrive at an understanding. The doctor tries to make sense of the patient’s story, of their symptoms and of the signs of disease in their bodies. A diagnosis unlocks the door to effective treatment, and by effective treatment I mean whatever encourages a restoration of health (though, sadly, many treatments don’t do that, they just either maintain the status quo, or slow the progression of the illness, but with less suffering).
Why shouldn’t diagnosis be a shared experience? Not just a label applied by the professional. One of my favourite diagnoses to illustrate this labelling behaviour is “Idiopathic Urticarial Syndrome”. A patient goes to the skin specialist with an itchy rash. They don’t know why they’ve got it. They don’t know what it is. But the skin specialist does. It’s “Idiopathic Urticarial Syndrome”. Well, here’s a secret. “Urticarial” means an itchy rash (OK, it’s a particular kind of itchy rash, one with “weals”, which is another word for “urticaria”). “Idiopathic” means in this particular case we don’t know what is causing it. If we knew what was causing it, it wouldn’t be idiopathic. It’d be an allergy to washing powder or whatever. “Syndrome” is a trick word. It’s sounds like the name of a disease but actually it’s a collective word for a group of symptoms (and maybe some signs). So, having sought help with an itchy, urticarial, rash whose origin is unknown to you and which you don’t understand, you now know you have an itchy, urticarial rash, whose origin nobody knows, and which nobody actually understands.

There is a different way.

Rather than seeing a diagnosis as an end point, it I can be thought of as a level of understanding. Then the doctor can take it as a step forwards, not a job done. A step towards a better, deeper, broader understanding of the patient. They can explore some of the mystery, the when, where and even the why of the illness. I think this is a form of education. It’s the doctor educating themselves about this particular patient.
An exploration of the circumstances of an illness, probing the when, the where and the possible why questions, is an opportunity for education for the patient too.
If somebody understands better what is going on, and what the initiating and maintaining factors might be, they can make other choices. Choices which might well lead to restoration of health.
One of my most favourite questions in a consultation was to ask the patient when they last felt completely well. It might take a bit of encouragement to get there, but most people can identify the period of their lives before this illness began. Having identified the time around the change from health to illness, I’d then explore what was happening in the patient’s life around that time.
I can’t tell you how many times that was like a light bulb going on. “Do you think my mother’s death might have had something to do with getting ill?” “Do you think losing my job, getting divorced and the death of my brother all in the same month might have had something to do with this?”
Of course, I could never answer a simple yes. It was just a helpful way to begin to explore the potential factors, their impacts, and what someone could do to tackle the ongoing effects.
I’m sure this isn’t possible in every single encounter, but it’s something to bear in mind. Ideally, all doctor-patient consultations can be therapeutic ones, and perhaps the best way for them to be therapeutic is when both the doctor and the patient learns something from the experience.
Learning from experience is definitely a powerful education.

One of my friends says “If everything that goes wrong is a learning experience I’d have a bloody PhD by now!”

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