{"id":44027,"date":"2019-02-07T12:26:22","date_gmt":"2019-02-07T11:26:22","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=44027"},"modified":"2019-03-15T09:42:08","modified_gmt":"2019-03-15T08:42:08","slug":"richard-smith-the-public-health-of-death-dying-and-grief-has-been-neglected-but-now-is-the-time","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/02\/07\/richard-smith-the-public-health-of-death-dying-and-grief-has-been-neglected-but-now-is-the-time\/","title":{"rendered":"Richard Smith: The public health of death, dying, and grief has been neglected, but now is the time"},"content":{"rendered":"

\"richard_smith_2014\"<\/a>The dying spend less than 5% of their time with doctors and nurses, and 95% doing something else, perhaps alone, with family and friends, walking the dog, making love, reading poetry, or watching the television. \u201cDying is not hard,\u201d said Alan Kellehear, 50<\/span>th<\/span> Anniversary Professor, End of Life Care, University of Bradford in London this week; it\u2019s what happens on the journey to death, which may last years, that can be hard: anxiety, depression, fear, loneliness, social isolation, stigma, looking into the abyss, and suicide. Yet palliative care concerns itself primarily with the 5% not the 95%. <\/span><\/span><\/p>\n

And the grief that starts before a death and continues after death lasts not for weeks, months, or years but forever. \u201cWhat are our forever strategies?\u201d asked Kellehear. \u201cGrief,\u201d he continued, \u201cis the least understood area of palliative care,\u201d and probably much more pervasive than we realise and an important ingredient of many social problems\u2014from gang stabbings through alcoholism and loneliness to suicide.<\/span><\/p>\n

The action with the dying and the grieving is not in hospitals, hospices, or primary care clinics but in homes, workplaces, schools, golf clubs, parliament, and the community\u2014which is why a public health strategy is needed. Yet palliative care, said Kellehear, is the only medical specialty that has paid no attention to prevention, harm reduction, or early intervention. It has concentrated only on the final phase of dying.<\/span><\/p>\n

The rudiments of public health<\/b>
\nJoking that he could save members of the audience \u00a39000, the cost of a masters degree in public health, Kellehear ran through the methods of public health before describing how they are now being used in relation to death and dying.<\/span><\/p>\n

Public education is one of the methods of public health, but like everything in public health it has a political component. Kellehear described how when he lived in Australia, messages about using a condom were everywhere when there were only 45 deaths a year from HIV\/AIDS. Yet not a single thing was done for the 100 000 a year dying and grieving.<\/span><\/p>\n

Community development must build on the community\u2019s needs not the paternalism of public health practitioners. It\u2019s about doing things \u201cwith\u201d people not \u201con people.\u201d Humility is needed, and, bemoaned Kellehear, public health professionals\u2014epidemiologists, health service researchers, and biostatisticians\u2014are the hardest people to get on board with community development; they are reluctant to get their hands dirty. Academic incentives, which reward intervention trials rather than community development, are wrong, argued Kellehear.<\/span><\/p>\n

Social ecology is manipulating the environment to get positive outcomes. Kellehear told the story of being asked to do something about the drunken carnage that happened every Friday night in Geelong in Australia. He and his team of researchers changed the environment with interventions like putting food on bars, either removing chairs or bolting them to the floor, insisting that gentle music be alternated with headbanging music, and telling the police not to arrest people unless there was a threat to life. The result was a 70% reduction in injuries. Crucially, the programme depended on having the full support of the city authorities.<\/span><\/p>\n

Sustainability is \u201cthe final and only test\u201d of public health programmes, said Kellehear. \u201cIf you [public health practitioners] are needed\u201d then you are providing a service not implementing public health.<\/span><\/p>\n

Compassionate communities and cities<\/b>
\nKellehear and others recognising how public health has failed to respond to death and dying have launched compassionate communities and cities that use the methods of public health. There are now as many as a thousand compassionate communities\u2014mainly in Australia, Britain, Canada, and India. There are about 40 in Shropshire.<\/span><\/p>\n

Every community is different, but there are, said Kellehear, two broad categories of compassionate communities: those that increase death literacy and awareness through death cafes, book clubs, poster campaigns, short story competitions, and the like; and those that create social support for those with long term illness or coping with grief and loss. Some communities combine the two. Kellehear favoured community support, saying he was \u201cnot a big fan\u201d of programmes to raise awareness. The box lists examples of activities undertaken by compassionate communities.<\/span><\/p>\n

 <\/p>\n\n\n\n
Examples of interventions used in compassionate communities<\/b><\/p>\n