International Health

Justmeans Health editorial  This is an editorial by Ano Lobb MPH on the JustMeans site (social entrepreneur website) that was posted today.  I was asked to do a technical review of the methods and content and given a chance to weigh in. For many people it is a shock to find out that all the discussion about the burden of disease and mortality are estimates because most countries to not have a system in place to count deaths. It seems like a simple thing to do but has not been given priority.  
 
International health study measures global mortality 

Posted On: May 20

A new international health study in The Lancet attempts to answer a seemingly simple question: What are the leading causes of death for children under age 5? That death rate is an often-used measure in international health, and reducing it is a UN Millennium Development Goal. The good news: despite a growing population, total deaths declined between 2000 and 2008 from 10.6 million to 8.8 million. Other interesting, if somewhat despair-inducing figures:

• Of the estimated 8.8 million deaths in children 5 years or younger, 68% were from infectious disease, including pneumonia (18%), diarrhea (15%) and malaria (8%).

41% of death occurred in neonates (under 1 month), with preterm complications (12%), birth asphyxia (9%), and sepsis (6%) being the leading causes.

Different high-death regions have different mortality profiles, with most deaths in sub-Saharan Africa occurring in those 1 month to 5 years, while deaths in China and India occurring more frequently in neonates.

In developed areas, genetic causes are a notable cause, something not widely seen, or at least reported or measured, in the developing world.

The methods of this paper are nearly as telling as the results. International health studies often report death rates, but deaths are not routinely counted in most of the world. Consequently, the authors present an exquisite flow chart with 33 different boxes depicting how they calculated their estimates. North America, parts of South America, Europe, Russia, Oman, Australia and New Zealand are the only areas routinely recording births and deaths. For the vast majority of the rest of world, some form of "verbal autopsy" is used as the basis for death estimates. In other words, asking a parent or family member, or perhaps health worker, what they think a child died from. International health expert Sharon McDonnell, MD, MPH, reviewed the paper for Justmeans.

"The verbal autopsy doesn't bother me so much," said Dr. McDonnell, whose career spans several decades with senior positions at both WHO and CDC. "It can be better than what is on paperwork via registries, so it doesn't necessarily speak to the quality of the data. It's often gathered at community level going door to door so it can be more likely to get accurate population estimates compared to health facility estimates."

Political factors also can't be overlooked in international health.

"The reporting of deaths in any way simply relates to whether the government has a system to count people. Most systems to count people were developed to tax them or send them to the military, sp there's little incentive to be counted on the part of the population. Westerners have a cultural frame of democracy and representation- having a voice. In many places you really don't want to stand out or be heard, it's best to blend in. Imagine the picture: a poor woman goes to a government official and says "my baby died". The official says "yes, so?"

"Until action and compassion are tied to reporting it is unlikely and almost irrelevant."

Photo credit: The Lancet