Monday, April 2, 2012

Matters of life and death*

When in 1968 I worked in Papua New Guinea, my credibility fell sharply when it became obvious several weeks after my arrival that my interest in epidemiology did not mean that I had the skill to diagnose and treat rare rashes and perplexing pimples.

Epidemiologists, famed neither for their sense of humour nor their warmth, have been defined variously as voyeurs who study populations broken down by age and sex, or (rather more engagingly) as magicians who convert death certificates into airline tickets.

In which case, have some sympathy for them. Death certificates are not as plentiful as you may think. A recent document from the World Health Organisation concerning ways forward in combating the universal scourge of chronic disease contains the following surprising information.

Only a third of the global population lives in an area where more than 90 per cent of births and deaths are registered. Currently, only 38 countries have high quality cause of death data, 81 countries have lower quality cause of death data, and 74 countries lack such data altogether. There are some encouraging signs of increased awareness of the need for better vital statistics among decision-makers, and use of information technology holds the promise of overcoming some persistent obstacles…National initiatives to strengthen vital registration systems, and cause-specific mortality statistics, are a key priority.

Now I fully accept that there is much more to good medical care than the information we record. The exceptional durability of the tatty paper-based hospital record alongside high-quality patient management is fair testimony: people get better and deaths are prevented yet we write down the scratchiest of detail – and we are one of the 38 countries deemed by WHO to have good statistics! Spare a thought for the others!

We may not do well with the quality of our medical records in Australia, but we do have a fine system for recording vital statistics, thanks to the Australian Bureau of Statistics, and we are in the top league. But reflect on what the state of the world’s vital statistics means for managing rationally the resources available to us to preserve and promote global health. Although anti retroviral drug treatment for HIV now has a substantial evidence base, in the early days of its application in Africa it was not possible to examine trends in HIV-associated deaths to see what it was doing. This is the problem: what to do and how to know how well we are doing in the absence of dependable evidence.

While the ‘vital’ in ‘vital statistics’ does not mean ‘can’t live without them’ but refers to the life (and death) of the individuals recorded in them, nevertheless global health progress is limited when we cannot get a clear picture of what needs to be done nationally and internationally, and we cannot discern accurately how well we are doing. The most basic of that information is the cause of death. We all know, and studies have confirmed, major inaccuracies occur even in this measure. Certificates that are completed ignorantly or incompletely cloud the picture. But not all is gloom.

First, in several less economically advanced countries, verbal autopsies, whereby relatives provide detailed answers about events surrounding the death of a decedent, have been used effectively to gain insight into causes of death, events surrounding the death (defective care, hazardous environment etc), and as a way of evaluating the effectiveness of interventions.

Second, the WHO points to the role of information technology in remedying this state of ignorance. In India, where information technology capability is high, we are seeing interesting developments. India has fine capabilities in demography and associated statistics. These are now being supplemented by the development of a universal electronic identification system, as I commented last month. This could have profound implications for health intelligence. Although privacy concerns are real, there are many circumstances where accurate medical data – even about causes of death – are an even greater necessity for effective planning of our health care future as a world community. Maybe the branch of epidemiology that studies death certificates still has life!

*Published in Australian Medicine April 2, 2012

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