Immediate, underlying, and macro-underlying causes

BMJ 2006; 332 doi: (Published 15 June 2006) Cite this as: BMJ 2006;332:1425
  1. Anna Goodman, masters student (anna.goodman{at}
  1. London School of Hygiene and Tropical Medicine, London

    When filling in death certificates, doctors list both the immediate cause of death and the underlying cause, be that a disease which initiated the train of morbidity leading to death or the circumstances surrounding the accident which produced a fatal injury. Identifying underlying causes in this way provides information of great importance to public health by highlighting the main sources of avoidable mortality in a population.

    I wonder, however, whether doctors have yet realised the full scope of the death certificate as a tool for compiling information to be used in guiding policy makers to the best way of promoting public health and wellbeing. For example, when recording the underlying cause of a heart attack in a manual labourer in his 50s, how about digging a little deeper than coronary artery disease to note the socioeconomic disadvantages that constrained this person's ability to quit smoking and take more exercise compared with people of higher socioeconomic status? Or, when recording the death of a teenager who crashed her car while over the legal alcohol limit, why not note the concerted efforts by the alcohol industry in the past decade to increase sales by marketing drinks aimed at young women?

    Of course, doctors are unlikely to be called on to make sociopolitical and economic judgments of this kind any time in the near future, and probably rightly so. As a thought exercise, however, I find the idea of introducing a “macro-underlying” section to the death certificate rather compelling. After all, what better way could there be for stimulating government action on issues of social justice than a sudden, sharp epidemic of deaths due to social inequality?

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