Key Words: Death, COVID- 19, Pandemics

Introduction

2019 ended with a socio- historical event that permeated all social and cultural structures. This event challenged and defeated even the most organized social responses in a few months. This causative agent – and all the effects provoked – soon became known worldwide as the COVID- 19 pandemic. In less than six months, the world’s population experienced the onslaught of an invisible, uncertain, and unknown enemy, paralyzing and transgressing every context. Social life was trans-formed from that moment on, but so was death. The research on the pandemic has focused on the virus, its infectiousness, post- infectious complications, and socio- economic implications. However, little has been said about death. Not death in quantitative terms, but as a socio- cultural phenomenon brought on by the pandemic.

According to Morin [1], what characterizes most living organ-isms is immortality and not death. This criterion lies in the fact that unicellular organisms reproduce by dividing to infinity and only encounter death when the external environment makes life impossible. For Maturana [2], the death of a living being con-sists of losing its own organization. In times of pandemic, death is an indicator of the devastating power of a virus, a bacterium, or other organisms to strain organized health care responses – even in the most advanced ones.

Since its recognition and formal naming, the COVID- 19 has become the global protagonist of suffering, pain, and loss. As Miguel- Tobal [3] points out, it awakened feelings of uncertainty and anxiety about death due to the threat (real or imagined) to one’s existence. This situation grew as infections and fatalities increased.

On the one hand, there was the ever- present fear of becoming infected, and on the other hand, there were those already infected with the fear of dying. Limonero [4] points out that this process is personal for people on the edge of death and depends on their characteristics, creeds, and healthcare assistance. Many deaths in the coronavirus pandemic were random, unexplained, and sudden. Unlike terminal illnesses, these deaths did not give the patient, the family, or the therapeutic team the necessary time to assimilate frustration, worry, fear, or guilt, among other emotions [5]. Death gradually became an everyday topic and was soon available as "a spoken death" [6], conveyed in culture through meanings and symbolism but constantly modified by historical contexts.

This paper reflects on three key points, which arise from the constellations around death that occurred in a historical moment marked by a global crisis. According to experts on the subject, this will not be the last pandemic. Therefore, these reflections point out guidelines of interest to conceptualize and manage death for future experiences of this magnitude.

The agony of the dying

A person’s deterioration from a COVID- 19 disease [7],[8] does not compare with the fear, pain, suffering, loneliness, anguish, and agony while waiting for an uncertain end: healing or death [9],[10],[11].

Death confined to hospital centers dates back to the early eighteenth century when the evicted were taken from their homes and families. Death assigned to a hospital [12] owns the sick person by institutionalizing him and taking away his social sup-port networks [13],[14]: "socially, the sick person is dead" [15].

Even though it is an unprecedented event, the coronavirus pan-demic reaffirms the right of all patients to be accompanied in the terminal phase of their lives by a family member, acquaintance, or even a person who can offer them spiritual care. In other words, they have the right to a dignified death [16],[17]. Dignified death must be protected in everyday situations and crises [18].

Technification and the urgency to find a cure have trivialized the spirituality or transcendence of one’s expiration, dehumanizing it just as care is degraded. Pandemic times invite us to think about agony and its effects, to which no one is acquainted, let alone prepared. Sudden death by COVID- 19 reminds us how vulnerable we are and invites us to be sensitive to a dying person’s needs and wishes and the importance of supporting and comforting them in the last moments of life. There is no act more dehumanizing and humiliating than dying alone.

This pandemic must have sensitized even the most rigid and bureaucratic parts of the health institutions because health care professionals found themselves alone in the face of death. These make us rethink this biographical stage of the human being and position it at the same level of importance as birth. A dying person is not a number in the mortality indicators but a human being with a life history, a family, and a role in society. This experience should appeal for accompaniment in the suffering and agony of the last memories of our existence.

Funerary and religious rituality

The pandemic revealed the importance of socio- cultural practices related to death and the funerary activities derived from it [19],[20]. The symbolic construction of the rituality surrounding death in times of coronavirus occurs in three moments. The first is the acute loss, instantly becoming a desperate and heart-breaking act. This mourning process is an opportunity to elaborate on the finitude of others and oneself.

The second moment refers to the lack of a final farewell to loved ones, as families were not permitted to be on the death-bed [12],[21]. This cultural phenomenon of depriving a family ritual of farewells is found in countless anthropological texts, typically occurring in nursing homes, hospitals, indigence [22],[23] and homicides, war conflicts, and kidnappings.

The third moment shows the cultural elements of beliefs and values about the funeral ritual per se. Cremation in this COVID- 19 era became a practice that changed the customs of millions of people, and in some countries, it was a strict guide-line for handling corpses not subject to wills. On the other hand, the mortuary celebration was reinvented, moving towards a virtual model that modernized religious ritual acts using computers and cell phone applications. The aim was to feel present in the funeral ritual, reduce the distance gap, and strengthen cultural and identity functions. It is interesting that online mortuary practices paradoxically homogenized cultural traditions globally by using electronic devices to promote the socialization of mourning and farewell.

This transformation and reinvention of funeral rituals indicate the importance of the last farewell to a loved one or acquaintance. This cultural act showed all the flexibility and attunement with necessities in the form of temporary, permissive, and tolerated syncretism.

Pilgrimage between doubt and guilt

This point refers to patients and their relatives who sought to solve a health problem, visiting several medical and professional centers without finding primary or specialty medical care [24]. Through the accounts in different primary sources, we can observe multiple journeys that patients and their families made searching for medical care and the emotions unleashed in this long pilgrimage (anguish, fear, haste, stress, and pain, among others). This journey became a complex collective imaginary. Allusion was made to hospital saturation [25],[26], the rejection of healthcare due to lack of medical personnel or absence of material and medical supplies to attend to the COVID- 19 emergency and the eco-nomic costs of patient transfers. This pilgrimage transitions between doubts about finding a place where the patient could be treated and the guilt of failing and threatening the patient’s life.

The journey begins with the intention of finding help but gradually builds anger and frustration with each denial of care, leading to physical and verbal expressions of violence and social rage.

The pilgrimage in times of pandemic exposes the inequity of a fundamental right to health and the lack of sufficiency of health supplies and human resources. Not only pilgrims went on pilgrimage to obtain oxygen or medicines (which is understandable in times of pandemic), but also terminal renal patients, cancer patients in search of chemotherapy, patients with surgical pathologies, and pregnant women who required specialized care. The pilgrimage seems to be the prelude to a slow and foretold death, especially for those who cannot afford private care.

Unlike religious pilgrimages, pilgrimages in search of health are saturated with pain, uncertainty, and fear of not reaching the place that will grant us recovery. Not only is the walking strenuous, but so is the waiting time to receive care. Both time and distance were decisive elements between life and death – many met their goal during the pilgrimage, but others did not have enough time to receive care.

Conclusions

In this historical moment, death was a protagonist. Death is interwoven throughout the pandemic’s social context and is accompanied by fear, pain, suffering, loneliness, anguish, and agony. This atypical death is sniffed, lurked, and even breathed in the COVID- 19 areas of hospitals, clinics, streets, homes, sidewalks, and public transportation.

From the reflection on the death process in the coronavirus era, three aspects are highlighted: the agony of the dying, the funeral rituals, and the pilgrimage between doubt and guilt. It is essential to problematize and study these aspects in greater depth – not only because they are situations associated with coronavirus infection – but also because we need to extrapolate these scenarios to other realities where death is slow and ignored by institutionalization. The normalization of the slow response of health institutions, the lack of access to health systems, and the lack of material and human resources, among other causes, also contribute to the latter.

COVID- 19 highlighted the critical knots in all the social responses organized for their attention and transformed the conception and treatment of death. In doing so, it reminded us how vulnerable and finite we are.

Notes

Contributor roles
FAD: conceptualization, formal analysis, research, writing, revision, and editing.

Competing interests
The author declares no conflict of interest with this manuscript.

Ethics
This paper does not require ethical approval.

Provenance and peer review
Not commissioned. Externally peer- reviewed by two reviewers, double- blind.

Language of submission
Spanish.

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