By Professor Tony Walter, University of Bath
The Office of National Statistics has recently published a visually attractive interactive chart on how the most common cause of death in England and Wales has changed each decade since 1915, broken down by age and gender http://visual.ons.gov.uk/causes-of-death-over-100-years/ Here I sketch some social, economic, cultural and psychological implications of these changes.
One dramatic change is the decline of deaths in those under 5: To quote ONS, “In 1915, there were 89,380 deaths of children aged under one, compared with just 2,721 in 2015. The number of deaths of one-to four-year-olds was 55,607 in 1915, while it was 460 in 2015”. Throughout history until the twentieth century, it was normal for children to grow up witnessing the death at home of one or more siblings and perhaps a parent. That was how children learnt about death. Today, thankfully, many people grow up without a close family member dying, let alone dying in the child’s home. This means that dying, funerals and grief are now things about which many young and even middle aged adults are largely ignorant. They therefore tend to defer to the expertise of health care and funeral professionals, thus furthering death’s professionalisation and the funeral’s commercialisation. Whether death is denied or taboo is debateable; but certainly there is ignorance and deference to professional expertise.
In 1915 infections and infectious diseases were, as in all previous societies, the most common form of death; this has now been replaced by chronic, non-communicable diseases (notably cancer) and by the deterioration of ageing organs (notably the heart and circulatory system). For women over 30, cancer has become the most common cause of death since the mid-twentieth century; for men, it is heart disease.
Different diseases have different ‘dying trajectories’. In terminal cancer, functioning may be maintained for months or years before a rapid decline a few weeks before death. Organ failure, by contrast, comprises a series of episodes (such as heart attack or stroke) each of which, though not fatal, reduces subsequent functioning until the final fatal episode; predicting this trajectory is harder than with cancer. End-of-life care as we find it today in the UK is rooted in the knowledge base of palliative care, developed in the second half of the twentieth century with less than elderly cancer patients. Many of palliative care’s tenets – such as patient choice and control – are premised on the cancer trajectory, and it is proving challenging to re-think end-of-life care in the context of multiple organ failure, often compounded by general frailty and possibly dementia. (This premise is not replicated in all countries. In the Netherlands, for example, palliative care arose out of elder care; while in Switzerland, it arose a bit later in the context of AIDS. Each country’s health care system thus has its own ‘spectacles’ through which it perceives end of life care.)
Widespread longevity into old age contributes to many features of contemporary society and economy that are easily taken for granted. Is it any coincidence that the age group most likely to die is given least status? In many ways, children and babies now have more personal and cultural significance than do the elderly – this would have been impossible in societies with high infant mortality rates. And marriages do not last significantly longer than a hundred years ago – they are just more likely to end in divorce than in death. So children are more likely to come from a home disrupted by divorce than by death.
Longevity’s effects on education and employment are dramatic. Long lives make higher education a worthwhile investment. In 1915, many began work at 13 and worked till they died or not long before. Now many do not start a career till their mid-twenties and retire in their 60s – so paid work may occupy only 40 out of a total of 90 years, with education and retirement featuring prominently. Combined with reduced fertility rates, longevity’s effect on women’s prospects is particularly marked. In all centuries before the twentieth, babies could occupy all or nearly all of a woman’s adult life, till she herself died – perhaps in childbirth. There are plenty of Victorian tombstones in my local churchyard depicting just such lives, with a list of infant and child deaths followed by the mother dying in her twenties, thirties or forties. Today, by contrast, babies may occupy only 5 out of 55 or more years of a woman’s life post-education; for the first time in human history, it is worth society investing in women’s careers. Arguably, feminism needed not only a reduced birth rate but also general longevity for it to have any chance of permeating everyday social and economic life.
By Professor Tony Walter, Honorary Professor of Death Studies, University of Bath
Latest book: What Death Means Now (Policy Press 2017)