FUNKOYA, Sierra Leone – Augustine Alpha begins gently. “Who lives in this house?” He asks the young man from the field to answer his questions.
Your name? Age? Religion? Marital status? What grade did you leave school in? Do you have a bike? Mr. Alpha stuffs the young man’s answers into his laptop perched on his thin knees.
Then comes the key question: “Has anyone died in your home in the last two years?”
“Yes,” says the young man, “my mother.”
Mr. Alpha expresses his sympathy, asks for his name – it was Mabinti Kamara – then dives in: Was he sick? How much? Fire? Rising and falling or steady? Vomiting? Diarrhea? trembling? Has he seen the doctor? Take drugs? There is pain? Where was the pain and how long did it last?
Mrs Kamara’s son was reticent at first, but was soon caught recounting the story of those last few weeks of his mother’s life, recounting his fruitless journeys to the local clinic. Mr. Alpha walks away until every detail is put into the software of a public health study called Countrywide Mortality Surveillance for Action, or COMSA. He then closes his laptop, puts a sticker on the wood shutter of the windshield showing the Kamara house as being viewed, reiterates his condolences, and moves on to the next house.
In this way, Mr. Alpha and his three colleagues will, in a matter of days, collect the details of every death that has occurred in the village of Funkoya since 2020, using a process called an electronic oral autopsy. The data they collect goes to the central office at Njala University in the town of Bo, a few hundred kilometers east of the project. There, a doctor reviews the symptoms and description and categorizes each death according to its cause.
An extraordinarily labor-intensive way of determining who and how died, but necessary here because only a quarter of deaths in Sierra Leone are reported to a national vital statistics registry, and no cause of death is identified. Life expectancy here is only 54 years, and the vast majority of people die from preventable or treatable causes. But with no data on the deaths of its citizens, the government of Sierra Leone plans its programs and health care budget based on models and projections, which are ultimately only the best estimates.
There are several reasons why families do not report the deaths of people like Ms. Kamara to a national registry, none of which are complicated. The registration office may be far away and cannot afford transportation, have time to get there, or pay the nominal fee for a death certificate. They may have never heard of this app; the state has little presence in their lives. The dead are buried behind their houses or in small village plots, as Kamara Hanım did; the local chief can then jot down the contents in a notebook that never leaves the village. Sierra Leone hospitals also do not automatically share death records.
Sierra Leone not an anomaly. Collecting vital statistics in the developing world is weak. While progress has been made in birth registration (which increasingly depends on access to education and social benefits) in recent years, nearly half of the people who die worldwide each year go undetected.
“There is no incentive in the death record,” said Prabhat Jha, head of the Center for Global Health Research in Toronto. Twenty years ago he pioneered such efforts to count the dead in India; Now doing this in Sierra Leone, one of the poorest countries in the world, has shown that the model can work anywhere and has helped support a government that is willing to base its policies on evidence and solid facts.
The topic of vital statistics record is not glamorous, but it is critical to understanding public health and socio-economic inequality. Covid-19 has brought a new interest to the subject. The debate over how many people have died from the coronavirus and who they are has become political, and lower death numbers in countries like India have served the agenda of national governments. hopes to downplay the role of failed pandemic policies.
Stephen MacFeely, director of data and analytics at the World Health Organization, said it’s important that we know not just how many people died, but who they were and when they died. “When we’re out of the eye of the storm, that’s when you talk about taking lessons.”
For example, there is fierce debate on this issue among epidemiologists. Are Africans dying from Covid-19 at the same rate? about people in other parts of the world and what can protect them if they are not.
Countries do not know who died and how, making efforts to reduce preventable deaths difficult. The government of Sierra Leone, as many developing countries do, allocates its budget based in part on models provided by UNICEF, the WHO, the World Bank, and other multilateral organizations that predict the number of people who will be killed by malaria there each year. typhoid, car accidents, cancer, AIDS and childbirth. These models are based on global predictions and are based on dozens of studies and individual research projects that can do a pretty good job of predicting the bigger picture, but are sometimes far less accurate at the national level. Dr. As Jha explains, malaria data from Tanzania or Malawi will not necessarily be accurate for Sierra Leone, even if all three countries are in Africa.
“You want countries to make decisions based on their own data, without relying on a university in North America or even the WHO’s Geneva office,” he said.
Information gathered through this painstaking door-to-door study has shown that models can be largely inaccurate. Dr. “When you count the dead, you only get information you didn’t expect,” Jha said.
The first COMSA study looked at the households of 343,000 people, of whom 8,374 died in 2018 and 2019. Oral autopsies have made such surprising discoveries that co-investigator of the project, Dr. Rashid Ansumana refused to believe them for months until the revelations were checked and rechecked in several different ways.
Dean of Njala University’s college of community health, Dr. “I was convinced by the facts and the evidence,” Ansumana said. “Now I can convince everyone: The data is great.”
The first big surprise was about malaria. Research showed it was the biggest killer of adults in Sierra Leone. Dr. Ansumana said he was taught in medical school that malaria kills children under the age of 5, but that people who survive childhood have an immunity that prevents recurrent malaria infections from taking their lives.
He said that almost everyone who works in healthcare in Sierra Leone believes this. In fact, the plotted data showed that malaria deaths formed a U-shaped curve, with numbers very high among young children and lower for young adults; The numbers then rose again for people over the age of 45.
The second shock was related to maternal deaths. The study found that 510 out of every 100,000 women die during childbirth – a surprisingly high rate, but still only half of what United Nations bodies reported for Sierra Leone. Dr. Ansumana said the finding is a relief for the government because it shows that the resources spent on making childbirth safer for women and babies are working.
Now, the second round of the national survey is underway, which seeks, among other things, to illuminate the health impact of Covid-19.
To secure such data without having to go door-to-door, Sierra Leone is working on reforms to citizenship registration and is one of many countries trying to figure out how to make sure more deaths are counted.
Many of these fixes are simple and don’t cost much, said Jennifer Ellis, who leads a program called Data for Health, run by Bloomberg Philanthropies, which aims to increase the collection of health data in low- and middle-income countries.
It begins with the overhaul of an existing death certificate. collect useful information about who died and whyand educating doctors to be aware of why a particular cause of death is important (for example, why it matters whether a death is recorded as “pancreatic cancer” rather than “abdominal pain”).
“You need to change the way data flows,” he said, as it could be collected by a national interior ministry and not shared with a health ministry. Data has to be digitized so it doesn’t just become stereotyped in notebooks. It should be easy and free for people to go somewhere and record a death.
Another step is the collection of routine oral autopsies for anyone who has died outside of a healthcare system. This includes identifying and training people at the community level, such as midwives or community health workers and others who can provide basic primary care in low-income countries, to try to gather information on each death.
Ms. Ellis said that digitization is expensive, but the cost of other steps is very low. Less than 5 percent of deaths in Zambia had a registered cause when Data for Health combined with the government in 2015; By 2020, this figure had increased to 34 percent. Peru has now launched a digitized cause of death reporting system that makes death information available in real time; It has reported some of the highest Covid death rates in Latin America as it has robust and rapidly accessible data.
Information gathered by new death registration systems was quickly translated into health policies. When improved cause-of-death collection revealed that traffic accidents were among the top causes of death in Colombia, its government acted quickly to introduce safety measures in the worst-affected areas. The death toll from snake bites in India has exceeded WHO’s estimate for the entire world; The antidote has been made available in more primary care centers in severely affected areas.
But while many countries are eager to translate what they learn from death statistics into policy, others are hesitant. “I’m not sure all governments really understand the power of data – and let’s be honest, many governments probably don’t want to measure it either,” said WHO’s Mr. MacFeely. Some see the higher Covid death numbers as an indictment of their pandemic response, he said.
Still, he said the WHO encourages countries to treat vital statistical data as they do other forms of infrastructure, such as gas systems or electricity grids.
“It’s part of running a modern country,” he said.
