tag:theconversation.com,2011:/au/topics/death-certificate-19903/articlesDeath certificate – The Conversation2023-02-15T13:23:22Ztag:theconversation.com,2011:article/1968712023-02-15T13:23:22Z2023-02-15T13:23:22ZHow records of life’s milestones help solve cold cases, pinpoint health risks and allocate public resources<figure><img src="https://images.theconversation.com/files/510099/original/file-20230214-2190-iexpcg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2117%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Civil registries in the U.S. are spread across different local jurisdictions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/several-certificate-of-vital-records-for-birth-royalty-free-image/1197564062">eric1513/iStock via Getty Images Plus</a></span></figcaption></figure><p>After 65 years, Philadelphia police announced in December 2022 that they had identified the remains of <a href="https://www.nbcphiladelphia.com/investigators/after-65-years-philadelphia-police-identify-the-boy-in-the-box/3445387/">Joseph Augustus Zarelli</a>, a 4-year-old boy who was murdered in 1957. Because no one had ever come forward to reliably identify Joseph, he became “<a href="https://www.hmdb.org/m.asp?m=194953">America’s Unknown Child</a>,” a moniker that captured the tragic anonymity of his early death.</p>
<p>Recent advances in DNA analysis and forensic genealogy <a href="https://www.cbsnews.com/philadelphia/news/boy-in-box-joseph-zarelli/">provided the needed breakthrough</a> to build a genetic profile that connected the boy to surviving members of his mother’s family. But linking that genetic profile to Joseph’s identity required finding his name, a piece of information stored alongside his mother’s on his nearly <a href="https://www.inquirer.com/news/philadelphia/joseph-zarelli-boy-in-the-box-dna-genealogy-cold-case-20221216.html">70-year-old birth record</a> in the Pennsylvania Department of Health’s vital records system. </p>
<p>While the revolutionary science of genetic genealogy has received <a href="https://www.cbsnews.com/philadelphia/news/boy-in-the-box-philadelphia-murder-mystery-dna-explainer/">well-earned recognition</a> for its contribution to solving this long-standing mystery, the integral role of the more staid vital records system has mostly gone unnoticed. </p>
<p>Vital records are the stalwart administrative backdrop to life’s milestone events: birth, adoption, marriage, divorce and death. When a child is born in the U.S., the parents and hospital staff complete and sign a <a href="https://www.cdc.gov/nchs/data/dvs/birth11-03final-acc.pdf">certificate of live birth</a> that includes nearly 60 questions about the parents, the pregnancy and the newborn. A local registrar issues a formal birth certificate upon receiving the record as proof of a live birth.</p>
<p>Other vital events follow a similar process. Collectively, the U.S. vital records system comprises <a href="https://www.ncbi.nlm.nih.gov/books/NBK219884/">records of hundreds of millions of events</a> dating back to the beginning of the 20th century.</p>
<p>As a <a href="https://scholar.google.com/citations?hl=en&user=J2RmiawAAAAJ">family demographer</a>, I use information from these vital records to understand how childbirth, marriage and divorce are changing in the United States over time. The scope and quality of these records reflect remarkable administrative coordination from the local to the national level, but examples from other countries illustrate how much more the records could yet tell us. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/E087KJy5f64?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">While DNA evidence was instrumental to identify “America’s Unknown Child,” vital records also played an important role.</span></figcaption>
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<h2>Vital records mark unique events</h2>
<p>Originally, vital records were intended to publicly register events in order to <a href="https://www.ncbi.nlm.nih.gov/books/NBK219870/">legally recognize</a> the status of the people involved. The two people named on a valid marriage certificate, for example, share the legal protections and obligations of marriage until death or divorce. But over time, vital records have also come to serve as proof of identity. For both purposes, the integrity of the vital records system is critical. </p>
<p>Practically speaking, the system requires a perfect symmetry between people and events. Every recorded event needs to be associated with a unique person or pair of people, in the case of marriage and divorce, and every person or pair needs to be associated with a unique recorded event. Because of this singularity, a <a href="https://travel.state.gov/content/travel/en/passports/how-apply/citizenship-evidence.html">valid birth certificate</a> is required as proof of an individual’s unique identity to obtain a Social Security card, driver’s license or passport. </p>
<p>The uniqueness of each event also underlies <a href="https://www.cdc.gov/nchs/nvss/births.htm">how birth, marriage, divorce and death rates are calculated</a>. Double-counted events will artificially inflate these rates, while uncounted events will reduce them. Valid rates are important because governments and businesses rely on accurate measures of population change for <a href="https://ncvhs.hhs.gov/wp-content/uploads/2018/01/NCVHS_Vital_Records_Uses_Costs_Feb_23_2018-1.pdf">planning and investment</a>. </p>
<h2>America’s local approach to vital records</h2>
<p>In the U.S., the vital records system isn’t a single entity. Rather, there is a collection of state and local vital records offices operating independently but in cooperation with the federal government. </p>
<p>Each U.S. state and territory, as well as New York City and Washington, D.C., is its own vital registration jurisdiction, amounting to <a href="https://www.naphsis.org/systems">57 areas in all</a>. And within each jurisdiction, local offices receive and process records and issue certificates. Nationally there are <a href="https://oig.hhs.gov/oei/reports/oei-07-99-00570.pdf">over 6,000 local registrar offices</a> issuing birth certificates in the city or county where a birth occurred. </p>
<p>In nearly all states, marriage licenses and divorce decrees are certified and filed at the courthouse in the county where the event happened. This local registration system explains why Nevada has the highest marriage rate in the nation: of the <a href="https://weddings.vegas/marriage-services/marriage-statistics/">over 77,000 marriage licenses issued</a> in 2021 in Clark County – home to Las Vegas, America’s wedding capital – more than 60,000 couples provided a home mailing address outside of Nevada.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Marriage license of Elvis and Priscilla Presley, with Elvis' portrait printed in the center" src="https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=474&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=474&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=474&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510128/original/file-20230214-18-l8wspj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Couples who flocked to get married in Las Vegas on 7/7/07 got a copy of Elvis and Priscilla Presley’s marriage license.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/detail-view-of-a-copy-of-elvis-and-priscilla-presleys-las-news-photo/75259026">Ethan Miller/Getty Images</a></span>
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<p>This highly decentralized approach has at least two significant implications. First, because different agencies are responsible for recording different events, there is no straightforward way to assemble an administrative profile for an individual over a lifetime. This challenge is further complicated when records are stored in different jurisdictions as people move and experience events in different places. Name changes – for example, through marriage – and inconsistencies in spellings, dates or other details also potentially impede record matching.</p>
<p>Second, in the absence of a single national repository for vital records, it takes substantial coordination to produce national statistics about vital events. Currently, U.S. jurisdictions send individual-level birth and death records to the <a href="https://www.cdc.gov/nchs/nvss/index.htm">National Center for Health Statistics</a> annually, and these records provide the basis for national birth and death statistics overall, including demographic characteristics like age, sex, race and ethnicity. This coordination is costly, time-consuming and often delayed. </p>
<p>In part because of the administrative burden, <a href="https://www.cdc.gov/nchs/nvss/marriage-divorce.htm">states stopped sending</a> detailed individual-level marriage and divorce records to the National Center for Health Statistics in 1995, and now provide only annual counts of these events. As a result, the only accessible way to examine national demographic patterns in marriage or divorce is through surveys, which are subject to nonresponse and reporting errors.</p>
<h2>Centralized approaches to vital recordkeeping</h2>
<p>In contrast to America’s decentralized system, <a href="https://unstats.un.org/unsd/demographic/sources/popreg/popregmethods.htm">many countries in Northern Europe</a> have centralized and integrated the collection and maintenance of administrative records related not only to vital events but also to circumstances like change in residence, employment and health care. This approach ensures that residents are <a href="https://www.ohchr.org/sites/default/files/Documents/Issues/Children/BirthRegistration/SwedenPopulationRegistration.pdf">continuously registered</a> to receive mail, vote, pay taxes, enroll in school and receive benefits such as housing subsidies at the correct address. It also means that public agencies have full information about their population to inform planning and budgeting.</p>
<p>A centralized system also facilitates rapid turnaround of population statistics. At peak periods during the COVID-19 pandemic, for example, the U.S. <a href="https://covidtracking.com/analysis-updates/how-lagging-death-counts-muddied-our-view-of-the-pandemic">lagged behind many other countries</a> in estimating national death rates as the Centers for Disease Control and Prevention awaited reported counts from public health offices in individual states overwhelmed by the pace and volume of deaths. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of infant's footprints on birth certificate" src="https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510118/original/file-20230214-28-1q5c7c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Vital records like birth certificates document your singularity as an individual.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/infants-footprints-on-birth-certificate-royalty-free-image/79250940">Tetra images/Getty Images Plus</a></span>
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<p>Vital records integrated with population register data also allow
social scientists, epidemiologists and other researchers to use deidentified linked records to study how <a href="https://ncrr.au.dk/danish-registers">early life conditions shape an individual’s life over time</a>. Using linked records from the Netherlands, for example, researchers have demonstrated that children who were in utero <a href="https://doi.org/10.1080/09603123.2021.1888894">during the 1944 Dutch famine</a> were more likely to have health problems throughout their lives than those born earlier or later.</p>
<p>The U.S. has made some progress toward developing a more centralized and integrated vital records system. A <a href="https://www.cdc.gov/nchs/nvss/linked-birth.htm">national file linking births to infant deaths</a> has helped scientists study how risk factors like preterm birth and low birth weight contribute to infant mortality. And public health and medical research studies can obtain cause of death information for participants in the <a href="https://www.cdc.gov/nchs/ndi/index.htm">National Death Index</a>, a compilation over 100 million death records since 1979. </p>
<p>But further progress is unlikely to happen any time soon. The current system, while cumbersome and incomplete, is well established and reliable. And at a time when the majority of Americans <a href="https://www.pewresearch.org/politics/2022/06/06/americans-views-of-government-decades-of-distrust-enduring-support-for-its-role/">lack trust in government</a>, there is little political will or public enthusiasm for a change. </p>
<p>For Joseph Zarelli, the durability of the local vital records system in Philadelphia was enough to answer a question that went unanswered for 65 years: A certificate of live birth registered in 1953 reconnected America’s Unknown Child to his name.</p><img src="https://counter.theconversation.com/content/196871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula Fomby receives funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. </span></em></p>Vital records document the birth, death, marriage and divorce of every individual. A more centralized system in the US could help public health researchers better study pandemics and disease.Paula Fomby, Professor of Sociology and Research Associate in Population Studies, University of PennsylvaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984012023-01-30T19:16:59Z2023-01-30T19:16:59ZHere’s who decides cause of death, how death certificates work – and whether a person died with or of COVID<figure><img src="https://images.theconversation.com/files/506975/original/file-20230130-23-hktw9z.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5613%2C3731&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>COVID was Australia’s <a href="https://www.theguardian.com/australia-news/2022/aug/08/covid-becomes-australias-third-most-common-cause-of-death-in-2022">third leading cause of death</a> (after heart disease and dementia) in 2022. In a <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2017%7EMain%20Features%7EDeaths%20due%20to%20influenza%7E5">bad flu year</a> we have about 1,200 influenza deaths. We had more than <a href="https://covidlive.com.au/">1,500</a> COVID deaths in just the first month of 2023. We need to take COVID seriously. It is not like a cold or the flu. It is an exceptional disease.</p>
<p>Because of the availability of vaccines and antivirals, there is no need for panic or further lockdowns. But there is no room for complacency either.</p>
<p>The starting point in taking COVID seriously is ensuring policymakers and the public have confidence in the data about who is getting sick and who is dying. Without accurate data, there is no way to track the disease or work out how best to contain it.</p>
<p>And a crucial part of this is ensuring people understand how death certificates work and how death data are recorded.</p>
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<a href="https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A stone angel sits atop a grave." src="https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506991/original/file-20230130-24-4j4f7z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Confidence in the data about who is getting sick and who is dying is crucial.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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Read more:
<a href="https://theconversation.com/thousands-more-australians-died-in-2022-than-expected-covid-was-behind-the-majority-of-them-196281">Thousands more Australians died in 2022 than expected. COVID was behind the majority of them</a>
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<h2>Dying of COVID or with COVID?</h2>
<p>A common misconception is that the numbers being reported are people who died with, not of, COVID. </p>
<p>Dying <em>of</em> COVID means COVID caused your death. Dying <em>with</em> COVID means you died from another cause, but just happened to have COVID at the time.</p>
<p>While we routinely collect data about both, a COVID death is when you die of COVID.</p>
<p>This misconception makes it easy to dismiss COVID deaths on the basis that the numbers being reported are exaggerated. Dismissing the numbers makes people complacent and lets governments off the hook. If we all pretend COVID is just a mild disease, there is no need for governments and individuals to do our bit to minimise its spread.</p>
<p>For most people whose vaccinations are up to date, COVID really is a mild disease. But about <a href="https://www.smh.com.au/national/we-re-all-vulnerable-one-in-10-people-will-end-up-with-long-covid-new-study-says-20230115-p5ccn5.html">one in ten</a> people infected with COVID go on to develop “long COVID” and the number of COVID deaths just keeps increasing as the pandemic drags on.</p>
<h2>How the system works</h2>
<p>The cause of every death in Australia must be certified by a medical practitioner. If the cause of death is not clear, the death is reported to the state or territory coroner for a coronial investigation. </p>
<p>After the cause of death is determined either by a medical practitioner or the coroner, a death certificate is issued and sent to the bureau of births, deaths and marriages in each state or territory. </p>
<p>From there, the data are sent to the Australian Bureau of Statistics, which is the independent statutory agency responsible for national statistical reporting.</p>
<h2>The death certificate</h2>
<p>The <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/1205.0.55.001Main%20Features12008?opendocument&tabname=Summary&prodno=1205.0.55.001&issue=2008&num=&view=">death certificate</a> records the immediate cause or the condition that led directly to death. It also records what are called “antecedent causes”.</p>
<p>Antecedent causes are the underlying causes. These are the conditions or events that occurred before the immediate cause. All other significant conditions that contributed to the death but were not related to the disease or condition that caused it must also be reported.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1617640127651799040"}"></div></p>
<p>So how does it work in practice? Imagine a family member dies of respiratory problems after having COVID. In this imaginary case, the direct cause of death is recorded as “acute respiratory distress syndrome”. The acute respiratory distress syndrome was due to pneumonia. In turn, the pneumonia was due to COVID. COVID is recorded as the antecedent cause of death. So the data may be recorded like this:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506971/original/file-20230130-16-2ulu5q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>The way medical certificates are written is important. They give us quite accurate data on who dies of COVID (where COVID recorded as the direct or the antecedent cause) and who dies with it (COVID recorded as an “other significant condition”). We use both of these pieces of information for different purposes.</p>
<h2>Professional judgment</h2>
<p>While the cause of a person’s death is usually clear, this isn’t always the case. Sometimes doctors and coroners have to exercise their professional judgement in determining the cause of death. </p>
<p>But this is a long way from claims on social media that medical practitioners and coroners are systematically reporting deaths “with COVID” as deaths “of COVID” as a way to exaggerate the COVID death toll. This is simply nonsense.</p>
<p>There are often time delays between a person dying and their death certificate being issued.</p>
<p>This is particularly the case for deaths referred to the coroner for investigation. In the interim, health departments around the country need data in real time so they can track the pandemic. They compile provisional COVID cause of death data as they go and then progressively update their data as death certificates are finalised. While this causes the numbers to fluctuate a little from week to week, the data used in official statistics are of very high quality.</p>
<p>Australian clinical training, standards and documentation are excellent by all international standards. Australia has well developed systems in place for the accurate reporting of the causes of death and illness.</p>
<p>These systems should inspire confidence in the numbers and that medical practitioners and coroners are reporting COVID deaths correctly.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/died-from-or-died-with-covid-19-we-need-a-transparent-approach-to-counting-coronavirus-deaths-145438">'Died from' or 'died with' COVID-19? We need a transparent approach to counting coronavirus deaths</a>
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<img src="https://counter.theconversation.com/content/198401/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathy Eagar does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The cause of every death in Australia must be certified by a medical practitioner. If the cause of death is not clear, the death is reported to the state or territory coroner for investigation.Kathy Eagar, Adjunct professor in the School of Clinical Medicine, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1916662022-09-30T04:20:18Z2022-09-30T04:20:18ZThe queen’s death certificate says she died of ‘old age’. But what does that really mean?<p>Queen Elizabeth’s <a href="https://www.nrscotland.gov.uk/news/2022/registrar-general-releases-extract-of-death-entry-for-hm-the-queen">newly released</a> death certificate contains just two curious words under her cause of death – old age.</p>
<p>We might talk about people dying of old age in everyday speech. But who actually dies of old age, medically speaking, in the 21st century?</p>
<p>Such a vague cause of death not only raises questions about how someone died, it can also be hard on family and loved ones left behind.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/why-do-we-mourn-people-we-dont-know-190331">Why do we mourn people we don't know?</a>
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<h2>The many ways people die</h2>
<p>The <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/latest#leading-causes-of-death">leading causes of death</a> in England and Wales are dementia and Alzheimer’s disease; heart disease; cerebrovascular diseases (such as stroke); cancer; and COVID. Other notable causes include chronic lower respiratory diseases (such as asthma); influenza; and pneumonia.</p>
<p>In fact, “old age” as a cause of death – alongside the vague description of “frailty” – is <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/monthlymortalityanalysisenglandandwales/august2022">often categorised</a> under “symptoms, signs, and ill-defined conditions”.</p>
<p>This latter category is in the top ten causes of death. But this currently trails well below COVID, and on average over a five year period, below influenza and pneumonia.</p>
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<em>
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Read more:
<a href="https://theconversation.com/how-australians-die-cause-3-dementia-alzheimers-57341">How Australians Die: cause #3 – dementia (Alzheimer's)</a>
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<h2>An interesting history</h2>
<p>Old age, as a category for causing death, has a <a href="https://www.cdc.gov/nchs/data/misc/classification_diseases2011.pdf">long history</a>. It was a leading cause of death in the 19th century, alongside the vague description of “found dead”.</p>
<p>In the mid-19th century, <a href="https://www.parliament.uk/about/living-heritage/transformingsociety/private-lives/death-dying/dying-and-death/registeringdeath/">registering someone’s death</a> moved from clerical to secular, with the Births and Deaths Registration Act 1836 (UK).</p>
<p>There was then the landmark publication, the <a href="https://www.amazon.com.au/Bertillon-Classification-Causes-Death/dp/1360651454">Bertillon Classification of Causes of Death</a>, written by French statistician and demographer Jacques Bertillon.</p>
<p>Canadian philosopher Ian Hacking <a href="https://www.google.com.au/books/edition/The_Taming_of_Chance/ud7EzIBwQBwC?hl=en&gbpv=1&printsec=frontcover">wrote</a> that dying of anything other than what was on the official list was “illegal, for example, to die of old age”.</p>
<p>We may say this is a bit hyperbolic. Surely, by the end of the 19th century, it was not illegal to die of old age?</p>
<p>What this suggests is that providing a precise cause of death is important because it’s a valuable tool for tracking mortality trends at different levels of the population.</p>
<p>Eventually, “old age” became a last resort phrase to describe an unknown cause of death. Or it became useful where a person may have died from a number of complications, but where it was not practical or ethical to order an autopsy to find the precise underlying cause of death.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/died-from-or-died-with-covid-19-we-need-a-transparent-approach-to-counting-coronavirus-deaths-145438">'Died from' or 'died with' COVID-19? We need a transparent approach to counting coronavirus deaths</a>
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<h2>There’s no closure</h2>
<p>The other reason why “old age” has been seldom used as the cause of death in the 20th and 21st centuries was that it doesn’t provide any closure to families of the deceased. </p>
<p><a href="https://eprints.qut.edu.au/221012/">Research</a> shows families want information about how their loved one died, not only because it can be useful for managing their own health concerns, but also because it provides a resolution to their loved one’s death.</p>
<p>An unknown cause of death can exacerbate grief and trauma, particularly if the death was sudden or unexpected. Researchers <a href="https://www.google.com.au/books/edition/Continuing_Bonds/e8a7NjkzsbsC?hl=en&gbpv=1&printsec=frontcover">have long argued</a> families form continuing relationships with their loved one after they die. Ascertaining how they died is one part of how the family members left behind manage their grief and memorialise the deceased.</p>
<h2>A good death</h2>
<p>We may decide that asking for more information about how the queen died at the age of 96 is just macabre titillation. We may decide the royal family deserves privacy surrounding intimate details of the queen’s death.</p>
<p>However, a specific cause of death of someone who lived a privileged life and who died at an old age, for instance, can tell us much about how to lead a healthy life and plan for a good death.</p>
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<strong>
Read more:
<a href="https://theconversation.com/friday-essay-on-reckoning-with-the-fact-of-ones-death-143822">Friday essay: on reckoning with the fact of one's death</a>
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<img src="https://counter.theconversation.com/content/191666/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc Trabsky receives funding from the Australian Research Council.</span></em></p>In the 19th century, ‘old age’ was once a leading cause of death, alongside the vague description ‘found dead’.Marc Trabsky, Senior research fellow, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1610682021-05-24T12:11:39Z2021-05-24T12:11:39Z578,555 people have died from COVID-19 in the US, or maybe it’s 912,345 – here’s why it’s hard to count<figure><img src="https://images.theconversation.com/files/402197/original/file-20210521-13-4t19hq.jpg?ixlib=rb-1.1.0&rect=1034%2C0%2C4716%2C2940&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A November 2020 memorial in Washington, D.C. consisted of thousands of flags, each planted to remember someone who died of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/on-the-eve-of-the-2020-presidential-election-the-last-of-news-photo/1283614255">Andrew Lichtenstein/Corbis via Getty Images</a></span></figcaption></figure><p>When the Institute for Health Metrics and Evaluation at the University of Washington released its <a href="http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths">estimate that COVID-19 had killed 912,345 people</a> in the U.S. by May 6, 2021, many were shocked. That’s 60% higher than the <a href="http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths">578,555 coronavirus-related deaths</a> officially reported to the U.S. Centers for Disease Control and Prevention over this same period.</p>
<p>How can <a href="https://nymag.com/intelligencer/2021/05/have-over-343-000-more-americans-died-from-covid.html">two estimates differ so widely</a>? It’s not like the Institute for Health Metrics and Evaluation researchers stumbled upon a morgue of more than 300,000 dead people who hadn’t been tracked elsewhere.</p>
<p>Here’s what goes into some of the various counts of COVID-19 pandemic deaths and how <a href="https://scholar.google.com/citations?user=kWGF578AAAAJ&hl=en&oi=ao">I as a statistician</a> think about their differences.</p>
<h2>Tracking deaths</h2>
<p>When someone dies, a medical professional records the immediate cause and up to three underlying conditions that “initiated the events resulting in death” on the <a href="https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf">death certificate</a>. Death certificate information is transmitted to the <a href="https://www.cdc.gov/nchs/nvss/index.htm">National Vital Statistics System</a> for a variety of public health uses, including tabulating the <a href="https://www.cdc.gov/nchs/nvss/leading-causes-of-death.htm">leading causes of death</a> in the U.S. </p>
<p>But death certificate information may not reflect the actual number of COVID-19 deaths. A COVID-19 diagnosis could have been missed by health care workers, or the disease could have gone unrecorded on a death certificate. There’s always going to be some error in the data. </p>
<p>One way to think about this is:</p>
<p>OBSERVED COUNT = TRUE COUNT + ERROR</p>
<p>That is, we want to know the real number of COVID-19 deaths in the U.S., the “true count.” But because the real world is messy, we’ll never know that true count and can only approximate it. The unknown true count combines with unknown errors to give us the observed count – for instance, the tally from all the nation’s death certificates.</p>
<p>If the predominant error is that some COVID-19-related deaths were missed – perhaps due to a lack of testing earlier in the pandemic – then the observed count would be an underestimate of the true count. However, there could be additional types of errors as well, and those may cause the observed count to deviate further or in other ways from the true count.</p>
<h2>Calculating ‘all cause’ excess mortality</h2>
<p>One way around this dilemma is to focus on how many deaths were recorded over and above the number expected by epidemiologists and statisticians had the pandemic not happened. This count is called “all cause” excess mortality. It’s based on historical data.</p>
<p><a href="https://doi.org/10.1111/1740-9713.01485">Estimates from this type of analysis</a> suggest that the reported number of COVID-19 deaths <a href="https://theconversation.com/279-700-extra-deaths-in-the-us-so-far-in-this-pandemic-year-147887">may be an underestimate</a>. Many more people died during the pandemic than normally would have during that time period. And it’s a higher number than how many people died of COVID-19 according to death certificate counts.</p>
<p><iframe id="Wb0re" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Wb0re/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>For example, the estimated number of deaths above what was expected in 2020 was almost 412,000 people, while the number of deaths the CDC attributed to COVID‐19 as of Jan. 6, 2021 was 356,000.</p>
<p>This type of analysis cannot conclude that the excess deaths are due to COVID-19 itself, only that the aggregate impact of the pandemic resulted in more deaths than would have been expected in its absence.</p>
<h2>Reconsidering the number of expected deaths</h2>
<p>So if by May 2021 there were 578,555 reported COVID-19-related deaths and perhaps as many as <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm">663,000 excess deaths according to CDC data</a>, how did the Institute for Health Metrics and Evaluation come up with the figure 912,345?</p>
<p>Their analysis seeks to determine the true number of COVID-19 deaths by estimating other effects due to the pandemic. IHME then uses its estimates of those effects to adjust the observed COVID-19 death count. </p>
<p>Some factors they considered would likely contribute to more deaths: health care that was delayed or deferred; mental health disorders that were untreated; increased alcohol use and opioid use during the pandemic. They also considered factors that would likely cut down on deaths: decreased numbers of injuries; reduced transmission of diseases that weren’t COVID-19.</p>
<p>They then used these estimates to adjust the expected number of deaths in an effort to better quantify the number of deaths attributable to COVID-19. In effect, they were applying these pandemic-specific “errors” to the excess death estimates that were based on pre-pandemic historical trends.</p>
<p>Ideally, this type of analysis should result in excess mortality being a better measure of the number of deaths that can be attributed to COVID-19. It depends, though, on having sufficient detailed data available and requires certain assumptions about that data.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="masked people stand outside in a socially distanced way" src="https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/402198/original/file-20210521-21-yrpa8b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Attendees at an April 2021 ceremony to memorialize people who died of COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/at-the-reading-hospital-in-west-reading-pa-thursday-evening-news-photo/1311683124">Ben Hasty/MediaNews Group/Reading Eagle via Getty Images</a></span>
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<h2>So which number is right?</h2>
<p>Such a simple question is actually quite hard to answer for many reasons.</p>
<p>One is that each number is the answer to a different question. The number of “all cause” excess deaths quantifies how many people died from any cause above what we would have expected if the death rate during the pandemic had followed pre-pandemic patterns. The Institute for Health Metrics and Evaluation number is an estimate of the total number of deaths that can be attributed to COVID-19. Both are useful for understanding the impact of the pandemic.</p>
<p>Yet, even two estimates of the total number of COVID-19 deaths are going to differ because the estimates could be based on different methodologies, different sources of data and different assumptions. That’s not necessarily a problem. It may be that the results turn out to be relatively consistent, suggesting the conclusions don’t depend on the assumptions. Alternatively, if the results are very different, that can help researchers understand the problem better.</p>
<p>However, even small differences between studies can, unfortunately, sow distrust in science for some people. But it’s all part of the <a href="https://theconversation.com/science-can-seem-like-madness-but-theres-always-method-4013">scientific method</a> in which studies get reviewed by researchers’ peers, <a href="https://theconversation.com/scientific-theories-arent-mere-conjecture-to-survive-they-must-work-73040">questioned and dissected, and then revised</a> as a result. Science is an iterative process in which gut instinct and guesses get refined into theories and then may be subsequently refined into facts and knowledge.</p>
<p>In this case, the Institute for Health Metrics and Evaluation study provides some evidence of what researchers like me suspected: The number of excess deaths in the U.S., while larger than the number of deaths attributed to COVID-19, may also be an undercount of the true number of COVID-19 deaths. It is also consistent with a <a href="https://www.nytimes.com/live/2021/05/21/world/covid-vaccine-coronavirus-mask#who-covid-deaths-excess">World Health Organization analysis</a> that concludes the number of COVID-19 deaths in some countries could be two to three times greater than the number recorded. But no single study offers definitive proof, just one more piece of evidence on the path to better understanding the deadly impact of this pandemic.</p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p><img src="https://counter.theconversation.com/content/161068/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald D. Fricker Jr. does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Record-keepers have a pretty good sense of how many people have died. But figuring out the cause of those deaths is a lot trickier – and that’s why reasonable modelers can disagree.Ronald D. Fricker Jr., Professor of Statistics and Senior Associate Dean, Virginia TechLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/485072015-10-09T04:00:11Z2015-10-09T04:00:11ZWhen communities help authorities tally births and deaths, health care equalises<figure><img src="https://images.theconversation.com/files/97750/original/image-20151008-9685-1q8mr4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Important information about death can be collected from a person's surviving relatives.</span> <span class="attribution"><span class="source">REUTERS/Mohamed Abd El-Ghany</span></span></figcaption></figure><p>Recent <a href="http://www.thelancet.com/series/counting-births-and-deaths">research</a> suggests that two thirds of deaths across the world are unrecorded. In addition, unrecorded deaths occur more frequently among disadvantaged people.</p>
<p>This raises important questions about the links between material and data poverty. And it has left researchers trying to understand how health authorities can interact with communities to improve these statistics. </p>
<p>Civil registration is the recording of births, deaths, marriages and divorces. The process of combining, analysing and reporting this data is known as vital statistics. </p>
<p>In many developing and transitional countries functioning civil registration and vital statistics systems are incomplete or absent. This has been described as the single most critical <a href="http://www.thelancet.com/series/who-counts">development failure</a> of the past 30 years. </p>
<p>The World Health Organisation says that only four of 54 African countries record more than <a href="http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Civil_registration_and_vital_statistics_systems">75%</a> of births and deaths. This seriously limits the capacity of the health system to respond to population health needs. </p>
<h2>Finding a solution</h2>
<p>Our research wants to address the unrecorded deaths worldwide. We want to develop a method which connects communities, health authorities and researchers to assess local situations, identify health priorities and plan for the future. </p>
<p>The project is a collaboration between the Medical Research Council and the Wits Rural Public Health and Health Transitions Research Unit (<a href="http://www.agincourt.co.za">Agincourt</a>), the <a href="http://www.abdn.ac.uk/iahs">University of Aberdeen</a> in Scotland and <a href="http://www.globalhealthresearch.net">Umeå University</a> in Sweden. </p>
<p>Our project consists of three phases over 18 months. We have just completed phase one and phase two is about to begin. It will be done in three poor and rural communities in the Agincourt research area in Mpumalanga, South Africa’s province with the <a href="http://mg.co.za/article/2014-06-12-a-district-in-despair">second highest</a> HIV rate. This will allow us to develop a method that can be adapted for use in poor communities in different locations.</p>
<h2>The value of verbal autopsy</h2>
<p>The first phase of the project will redefine how deaths are recorded. Currently deaths are recorded using medical information. Less attention is paid to the critical limiting factors that arise from the health systems and social contexts.</p>
<p>This phase is helping us understand incomplete health data, particularly among disadvantaged groups. It is also helping us understand the social and health system contexts that influence how deaths occur. Official health data, used to plan services, often fails to account for this.</p>
<p>The phase used <a href="http://www.who.int/healthinfo/statistics/verbalautopsystandards/en/">verbal autopsy</a>, interviewing relatives of people who died. They were questioned about the medical signs and symptoms of the person before they died. The data is used to conclude probable medical causes.</p>
<p>Verbal autopsy is applied in over 45 low and middle-income countries and has become an established research method. It provides crucial burden-of-disease information in otherwise uncounted populations.</p>
<p>Verbal autopsy has gained considerable momentum since it was introduced in the <a href="http://epirev.oxfordjournals.org/content/32/1/38.long">1950s and 1960s</a>. Today it is a scalable solution to strengthen civil registrations and vital systems. In 2012 the World Health Organisation released a <a href="http://www.who.int/healthinfo/statistics/verbalautopsystandards/en">short form</a> for it to be implemented more widely. In 2014 and 2015 ministerial conferences were held in <a href="http://www.getinthepicture.org/">Asia</a> and <a href="http://ea.au.int/en/content/%203rd-African-Ministers-responsible-for-Civil-Registration">Africa</a> to promote verbal autopsies in civil registrations and vital systems.</p>
<p>The researchers used the standard verbal autopsy method to collect additional information about access to health care and social circumstances at the time of death. From this, extended systems which classify deaths will be developed to account for social and health systems contexts. The team will also explore how the information can be integrated into health planning.</p>
<h2>Building a knowledge base</h2>
<p>In the second phase, the researchers will use the new data to work with local communities so that the authorities can act on the newly acquired health information. These discussions will also help them pinpoint the priorities for local services and what the potential co-benefits will be to empower these communities and socially include everyone.</p>
<p>It will help authorities to deepen their understanding of the mechanisms that shape the social and health systems used by the poor. It will also encourage a more democratic knowledge production on health which can then be acted on.</p>
<p>Through this community-based analysis, which capitalises on the long-standing relationships between communities and researchers in <a href="http://www.agincourt.co.za/index.php/activities/linc">Agincourt</a>, complementary accounts of cause of death will be developed.</p>
<p>In the final phase, using the robust evidence, researchers and health authorities will develop a practical way to strengthen the health system in the long term.</p>
<p>This will result in a method to generate health data more rigorously at population level, which uses an inclusive process so that there can be sustainable health gains through better data and improved capacity for evaluation.</p>
<h2>Working together is key</h2>
<p>This work is <a href="http://www.equinetafrica.org/bibl/docs/PAR%20Methods%20Reader2014%20for%20web.pdf">action oriented</a>. It aims to connect communities, researchers and health authorities and is a response to the lack of meaningful connections between research and policy observed in <a href="http://www.nature.com/nature/journal/v463/n7282/full/463733a.html">South Africa</a> and <a href="http://www.who.int/alliance-hpsr/resources/publications/9789241504409/en">elsewhere</a>.</p>
<p>For researchers the significance of registering all individuals in a population is that the researcher will be able to move towards a more people-centred methodology for their health systems research. For health authorities, it will result in better health planning, which ultimately will help the citizens get better health services.</p><img src="https://counter.theconversation.com/content/48507/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucia D'Ambruoso receives funding from the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust and the UK Department for International Development.
Lucia D'Ambruoso is affiliated with the Umeå Centre for Global Health Research in Sweden.</span></em></p>Health authorities need to bridge the gap and connect with communities to successfully identify health priorities and plan for the future.Lucia D'Ambruoso, Lecturer in Global Health, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/482672015-10-02T04:39:40Z2015-10-02T04:39:40ZCounting every birth and death could make a difference to health inequities in Africa<figure><img src="https://images.theconversation.com/files/96798/original/image-20150930-5798-j553su.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most African countries record less than 75% of their births and deaths. </span> <span class="attribution"><span class="source">Reuters/Andreea Campeanu </span></span></figcaption></figure><p>For many African countries and especially among poorer communities, when people die there is no trace in any official legal record or statistic. It is common for a person who lives in the city and falls terminally ill to return to their rural village to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825805/pdf/ukmss-28804.pdf">await their death</a>. When they die they are buried without any legal or official documentation of the death specifying the cause. </p>
<p>At the same time millions of births in Africa are not <a href="http://www.unicef.org/esaro/Technical_paper_low_res_.pdf">legally documented</a>. In developed countries this would be unheard of.</p>
<p>In Australia and Denmark, <a href="http://www.who.int/healthinfo/civil_registration/crvs_report_2013.pdf">99%</a> of all deaths are captured. But only four out of 54 countries in Africa – Algeria, Mauritius, Seychelles and South Africa – capture <a href="http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Civil_registration_and_vital_statistics_systems">75%</a> or more of their births and deaths. </p>
<p>Africa’s situation is mainly due to problems with what is known as civil registration and vital statistics systems.</p>
<p>And this is detrimental for planning purposes on the continent. If we do not know how many people are dying and why they are dying we cannot do much to prevent deaths that could have been avoided. </p>
<p>Many African governments were unable to monitor the <a href="http://www.un.org/millenniumgoals">millennium development goals</a> because they lacked the vital statistics, especially in the area of infant and maternal health.</p>
<p>A well-functioning civil registration and vital system that makes every death and birth in Africa count will be crucial to monitor the progress in achieving the newly set <a href="https://sustainabledevelopment.un.org/topics">sustainable development goals</a>.</p>
<h2>The marks of a well functioning system</h2>
<p>According to the <a href="http://www.who.int/healthinfo/civil_registration/en/">World Health Organisation</a>, a country has a well-functioning civil registration and vital statistics system if it registers all births and deaths, issues birth and death certificates and compiles and disseminates birth and death statistics, including cause-of-death information.</p>
<p>Other “vital” events that could be captured by the system are marriages, divorce and migration. These statistics are needed to inform local authorities that have to allocate public resources and monitor health progress. </p>
<p>A well-functioning civil registration and vital statistics system needs to be:</p>
<ul>
<li><p>universal to include all areas and the country’s entire population;</p></li>
<li><p>continuous to record vital events as they happen and on a permanent basis;</p></li>
<li><p>compulsory and be backed by a legal framework for its administration, operation and maintenance; and</p></li>
<li><p>confidential to retain public confidence by protecting citizens from misuse of records for legal matters.</p></li>
</ul>
<p>Despite the well-documented benefits of civil registration and vital statistics systems, many countries in Africa have not managed to get it right. </p>
<p>In Kenya for example, only about 46% of deaths and 60% of births are registered by the civil registration and vital statistics system. And even so, there are disparities within the country. In Kenya’s far-flung rural Mandera County, which borders Somalia, only 3% of deaths and 17% of births are said to be registered. </p>
<p>In general, poorer and more remote communities tend to be excluded from these systems. This fosters health inequities. It renders deaths and births in such communities invisible to local authorities. And if local authorities can’t determine how many people are dying, why they are dying, or how many children are born, they can’t plan for or respond to the health needs of the communities.</p>
<h2>Africa’s challenges</h2>
<p>There are several reasons why these systems remain ineffective. First, many policymakers are largely unaware of the value and importance of these systems. As a result, civil registration and vital statistics systems are not backed by strong governance frameworks or policies. Nor are they adequately funded and resourced. </p>
<p>The laws and procedures guiding civil registration and vital statistics systems in some African countries date back to the colonial era. This means they are not relevant or implementable today. </p>
<p>But there are also infrastructural and technological challenges. Many countries still rely on paper-based records for their systems. This is in contrast to Denmark, where, for example an electronic system was established as far back as 1968. </p>
<p>In the past decade various global and regional initiatives have been aimed at improving these systems in the developing world. In one such initiative, the World Health Organisation partnered with the Health Metrics Networks to create the Monitoring of Vital Events through the use of information technology, also known as the <a href="http://www.who.int/healthmetrics/move_it/en/">MOVE-IT</a> project. </p>
<p>The project successfully piloted electronic death registration systems in Kenya and Mozambique. But its greatest limitation was being project-based. It focused solely on collecting statistics rather than creating a coordinated and comprehensive approach to strengthen civil registration and vital statistics systems.</p>
<p>There are renewed and more co-ordinated efforts to improve systems in Africa. </p>
<p>The Economic Commission for Africa, with the African Union Commission, the African Development Bank and other key regional and international organisations developed a regional policy and advocacy <a href="http://www.uneca.org/sites/default/files/images/apai_crvs_23-august-final-formatted.pdf">framework</a> to speed up civil registrations and vital systems. </p>
<p>Ministers across the continent responsible for civil registrations are supporting its implementation. They pledged their political commitment at a civil registrations conference in Ethiopia in 2010. </p>
<p>Earlier this year they met in Yamoussoukro, Côte d’Ivoire where they agreed to launch a ten-year <a href="http://www.uneca.org/stories/ministers-propose-2015-2024-decade-civil-registration">programme</a> supporting civil registrations and vital statistics until 2024. Their goal is to leave no child or country behind.</p>
<h2>Developing a comprehensive approach</h2>
<p>The meetings in 2010 and this year have brought much-needed political commitment to improve civil registrations and vital systems in Africa.</p>
<p>The initiative provides the policy and programmatic framework to strengthen these systems across the continent, backed by the necessary political goodwill. </p>
<p>This sets the stage for all countries to comprehensively assess their systems and prepare costed national action plans to improve them, irrespective of their state of development.</p><img src="https://counter.theconversation.com/content/48267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Oti receives funding from Bill & Melinda Gates Foundation, and International Development Research Center. </span></em></p>In Africa, only four countries record more than 75% of their births and deaths. This creates an unequal system and impacts on how governments plan for these citizens.Samuel Oti, Senior Research Officer, African Population and Health Research Center, and Millennium Promise Fellow, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/466442015-09-02T05:35:37Z2015-09-02T05:35:37ZWorldwide, 65% of deaths go uncounted – here’s how to change that<figure><img src="https://images.theconversation.com/files/93336/original/image-20150828-19943-lt4yds.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Burial in Madagascar, 2013</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=liBoMtFRrjPB-eTXPn9qcw&searchterm=africa%20funeral&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=220233388">Dennis van de Water</a></span></figcaption></figure><p>It has <a href="http://www.sciencedirect.com/science/article/pii/S0140673607614184">been described</a> as the most critical development failure of the past 30 years, and shows no sign of improving: many countries’ systems for registering major life events like births and deaths are incomplete or absent. </p>
<p>In 2007, the Lancet <a href="http://www.thelancet.com/series/who-counts">described the situation</a> as follows: “most people in Africa and Asia, and in many other regions, are born and die without leaving a trace in any legal record or official statistic”. A follow-up series in 2015 <a href="http://www.thelancet.com/series/counting-births-and-deaths">identified</a> a continued lack of political will to improve the situation. Registration of major life events is fundamental to human security and development, but 65% of deaths and 35% of births remain unrecorded across the world. </p>
<p>Civil registration refers to the continuous recording all vital life events in a population (also including marriages and divorces). It brings benefits for everyone. It provides citizens with the legal documents that allow them to protect rights like identity, citizenship and property; enabling them to make claims for public goods such as housing, employment, health care and justice. It helps to protect people, especially the vulnerable, from harm and exploitation in times of disaster or conflict, as well as from human trafficking and child labour. And it ensures that countries’ vital statistics are available for those that need to see them. </p>
<h2>A health essential</h2>
<p>Registering medical causes of deaths has also <a href="http://www.encyclopedia.com/topic/vital_statistics.aspx">long been considered</a> essential for the health of a population. The fact that more than half of all deaths worldwide go unregistered seriously limits the capacity of national health systems to deliver services that respond to the needs of their population. And poor countries are by far the worst affected: governments struggle to establish proper systems and donors often prefer to invest in interventions targeting specific health problems, such as vaccines, bed nets, clean birth kits and so forth. </p>
<p>Civil registration also plays an important role in helping development agencies monitor policies and programmes. Last month, <a href="http://uk.reuters.com/article/2015/08/03/uk-un-development-goals-idUKKCN0Q70Y520150803">the world agreed</a> 17 goals for sustainable development to continue the <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a> beyond the 2015 deadline. An aspirational vision of global health and development this may be, but it will fail those it seeks to service if its success is judged on indicators that countries don’t measure. </p>
<p>We therefore urgently need alternatives that can record vital health data. The most obvious option is <a href="http://www.cghr.org/projects/million-death-study-project/what-is-verbal-autopsy/">verbal autopsy</a>, which has already been used in more than 45 low and middle-income countries for more than two decades to determine the causes of death for people who die outside hospitals and health facilities and/or in places where registration practice is poor. It has been used in countries as diverse as <a href="http://www.who.int/bulletin/volumes/90/3/11-092452/en/">Pakistan, Guatemala</a>, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4490796/">Malaysia</a> and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022330/">Kenya</a>, often to gather information about a specific condition, such as <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022330/">sickle cell anaemia</a>, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3040016/">stillbirth</a> or <a href="http://www.who.int/bulletin/volumes/90/3/11-092452/en/">child mortality</a>. </p>
<p>It involves trained fieldworkers interviewing final caregivers on the deceased’s medical signs and symptoms prior to death. This information is then interpreted to deduce the probable medical causes. Admittedly it cannot help with the problem of vital documentation, which is one of the reasons it should be seen as an interim measure, but it still has an important role to play. </p>
<p>Not only can it address the critical gaps in our knowledge on world health – Ebola incidence is a good example – it can also shed light on specific issues like exclusion from access to health systems. And contrary to what you might imagine, it <a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70340-7/fulltext?rss=yes">doesn’t have to be</a> very expensive to implement. </p>
<h2>The international push</h2>
<p>We’ve now reached the point where there is considerable momentum around scaling up verbal autopsies. The World Health Organization regularly publishes standard verbal-autopsy interviews to harmonise practice and allow cross-national comparisons. In 2012 it <a href="http://www.who.int/healthinfo/statistics/WHO_VA_2012_RC1_Instrument.pdf">published</a> a formal short verbal-autopsy template to encourage them to be used more widely, as well as using them to contribute to the likes of <a href="http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/">maternal mortality data</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=812&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=812&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=812&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1020&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1020&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93340/original/image-20150828-19916-1llnpvy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1020&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Signs of change?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=liBoMtFRrjPB-eTXPn9qcw&searchterm=africa%20funeral&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=291072362">Myimages - Micha</a></span>
</figcaption>
</figure>
<p>The use of verbal autopsy as part of civil registration was also promoted at a <a href="http://www.unescap.org/events/ministerial-conference-civil-registration-and-vital-statistics-asia-and-pacific">ministerial conference</a> on civil registration in Asia in 2014, and at a <a href="http://ea.au.int/en/content/%203rd-African-Ministers-responsible-for-Civil-Registration">similar event</a> for Africa earlier this year. Meanwhile the <a href="http://www.interva.net">latest development</a> is automated interpretation of verbal autopsy data, which makes interpretations between different regions and countries fully consistent. </p>
<p>The University of Aberdeen is involved in these efforts by co-ordinating a <a href="http://www.abdn.ac.uk/news/7999/">new research initiative</a> that aims to help exploit another opportunity presented by verbal autopsies: reconciling health data with information about the broader social circumstances that contribute to avoidable deaths. </p>
<p>Focused on South Africa, the work will develop new ways to classify deaths according to the local social circumstances that contribute to them; work with local communities to make the interpretations as accurate as possible; and embed these data and interpretations into national health systems. Like the rest of the efforts to improve recording of deaths through verbal autopsies, the hope is that by increasing the stock of knowledge about world health, we go some way to helping the people who suffer most from the lack of it.</p><img src="https://counter.theconversation.com/content/46644/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucia receives funding from the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust and DFID. She is affiliated with the Umea Centre for Global Health Research at Umea University in Sweden.
</span></em></p>One of the biggest problems in international development is that health statistics are badly kept in many of the countries with the most to gain. Finally something is being done about it.Lucia D'Ambruoso, Lecturer in Global Health, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.