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The death of Nobel laureate in chemistry Richard Heck in Manila early this October raises questions about the way society care about the end-of-life of its senior citizens.
Heck, along with Japanese scientists Ei-ichi Negishi of Purdue University in the United States and Akira Suzuki of Hokkaido University in Japan, won the Nobel Prize in 2010 for successfully cross-coupling carbon molecules using palladium as a catalyst.
Ironically, Heck died without getting the needed medical attention because he lacked the money to pay for the hospital expenses his family complained.
He worked for 18 years at the University of Delaware where he became professor emeritus but the American chose to retire with his Filipino wife in Manila. He relied on his monthly pension of US$2,500, an amount that would not have been enough if he lived his retirement years in the US.
He suffered for years from diabetes, chronic obstructive pulmonary disease and slight dementia. He had unpaid medical bills when he was brought to a hospital where he died at the age of 84, after exhausting his life savings on medical care.
Quality of life and death
Heck’s demise in the Philippines raises the social security issue, a problem that even rich countries like the US are struggling with. As the world’s population gets older, the social security system has more senior citizens to support and fewer younger people to contribute to the system. Unless the system is changed, it will eventually break down.
The Worldwide Hospice Palliative Care Alliance says only in the last few years have leaders paid attention to the issue of dying with dignity and started investing in high-quality and affordable palliative care for the dying population. 
This is because, although inevitable, death is not something people discuss in daily conversation. It is taboo in many cultures. And yet, although most people do not want to talk about it, everyone wants a “good death” or rather, “a good life to the very end”.
So what does a “good death” mean? In 2010, the Economist Intelligence Unit (EIU) was commissioned by the Lien Foundation of Singapore to come up with an answer. The goal was to draw up a Quality of Death Index to evaluate countries on the quality of care they give to people who are dying. The index was revised and expanded in 2015. 
The new and expanded 2015 index evaluates 80 countries using 20 quantitative and qualitative indicators across five categories: the palliative and healthcare environment, human resources, the affordability of care, the quality of care and the level of community engagement.
The main criterion for the Quality of Death Index is palliative care, defined by the WHO as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through…relief of suffering…and treatment of pain and physical, psychosocial and spiritual problems”. 
The EIU used official data and interviewed palliative care experts to construct the index. It noted that the proportion of older people in the population is growing and non-communicable diseases such as heart disease and cancer are on the rise. The need for palliative care is therefore expected to increase.
Quality of death rankings
According to the EIU 2010, as well as the 2015 index, the United Kingdom has the best quality of death because of its comprehensive national policies, extensive integration of palliative care into its National Health Service, and a strong hospice movement.
Income levels are a strong indicator of the availability and quality of palliative care, with rich countries topping the Index. Australia and New Zealand come second and third on the list, and four other comparatively developed Asian countries rank in the top 20: Taiwan at 6, followed by Singapore at 12, Japan at 14, and South Korea at 18.
Otherwise, developed European countries dominate the top 20 together with the US and Canada at ranks 9 and 11, respectively.
Ability to provide palliative care may be related to the wealth of the country. But there are some exceptions to the rule, demonstrating the power of innovation and initiative.
An example is Panama, which is building palliative care into its primary care services. Other examples are Mongolia, which has beefed up its hospice facilities and educational programmes, and Uganda, which has increased availability of opioids.
The other Asian countries cluster around the middle to lower half rankings of the 80 countries included in the Quality of Death Index: Malaysia (38), Thailand (44), Indonesia (53), Vietnam (58), Sri Lanka (65), India (67), China (71), Myanmar (76), Philippines (78), Bangladesh (79) and Iraq (80).
Asian social safety net?
Asked to comment on the Philippines’ very low rankings, Philippine Health Insurance (PhilHealth) vice-president Francisco Soria tells SciDev.Net that the “government social health insurance system takes care of the curative needs of the population and not yet the palliative care for the old and dying, which is just beginning to be discussed”.
“In the Philippines, care for the dying is undertaken by close family members, which is probably a better arrangement emotionally and psychologically for the patient. It is not in Philippine culture to put patients away in an institution for palliative care,” Soria adds.
In many other Asia-Pacific countries, social safety nets provided by the strong family systems should be taken into account when determining the criteria for the Quality of Death Index.
If these initiatives provided by the social safety net were taken into account, I think the ranking of the Philippines and other Asian countries would go up.
For example, my wife has hired a caregiver to give personal and hygiene care to her brother who is bedridden due to old age. He is living the rest of his days in comfort in his home, with his family around him, without depending on the government’s PhilHealth insurance system.
Years ago, we had a caregiver who took care of my mother in the home of my sister, and my mother died comfortably at 88. After that my wife and I cared for her father in our home, with the assistance of a caregiver. He died at 86.
I am sure there are plenty of such examples in Asian societies. So when we talk of Quality of Death Index, we do not think only of government programmes to care for the aged and dying but also the social safety nets that Asia-Pacific societies provide.
Crispin Maslog is a former journalist and science journalism professor at the University of the Philippines Los Baños and director of the Silliman School of Journalism, Philippines. He is a consultant of the Asian Institute of Journalism and Communication and board chairperson of the Asian Media Information and Communication Centre, both based in Manila.
This article has been produced by SciDev.Net's South-East Asia & Pacific desk.
 The Economist Intelligence Unit Quality of Death Index 2015: Ranking palliative care around the world (accessed 20 October 2015)