Why Do We Not Know What Children Are Dying of in Poor Countries?

In a brilliant keynote speech given on November 2 to open the 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene ( ASTMH), Bill Gates—philanthropist and champion of global health—made particular reference to a problem that he appears to have been concerned about in recent years: the need to improve epidemiological surveillance of the diseases that continue to kill children in the world’s poorest countries. This is a concern—one that I share—that warrants the attention of everyone who cares about global health, and we need to reflect on the problem together.

Although it may be hard to believe, today, in the 21st century, we still do not know the cause of most of the childhood deaths that occur in the world Although it may be hard to believe, today, in the 21st century, we still do not know the cause of most of the childhood deaths that occur in the world. The tools currently available are extremely inaccurate. In the few places where the verbal autopsy method is available, estimates are based on data obtained though standardised interviews with the children’s families. A generic model of the questionnaire used has been aptly proposed by the World Health Organization (WHO) as a way to ascertain cause of death when better methods are not available. During the interview, the family are asked about the presence or absence of a series of clinical symptoms (fever, cough, diarrhoea, etc.) and to describe the events preceding the child’s death. The data obtained from these interviews are then interpreted to ascertain the most likely cause of death. The analysis is carried out either by a team of doctors or by a computer program using a series of complex algorithms.

Obviously this method has many disadvantages and the estimates obtained are highly subjective and often erroneous. It would be a great step forward if we could develop alternative methods for assessing the underlying cause of death in these situations; for example, methods based on histological and microbiological findings obtained from samples obtained post-mortem. Work is still needed to evaluate whether such methods, which have been shown in theory to have a diagnostic capacity similar to that of a complete autopsy, would be acceptable in the areas where they would be most useful. Complete autopsy, the technique currently considered to provide the most accurate information on cause of death, is seldom used in the world’s poorest countries owing to the chronic shortage of trained pathologists and, above all, because the practice is often unacceptable to the community. In this context, the encouraging results presented at the ASTMH Congress a few days ago by a team of ISGlobal researchers working to develop this innovative method were welcomed by the international community as a breath of fresh air in this epidemiologic field that has, until now, been somewhat stagnated.

It would be a great step forward if we could develop alternative methods for assessing the underlying cause of deathSince it was set up in 1994, the philanthropic foundation chaired by Bill Gates and his wife Melinda has invested more than 28 billion in many initiatives, with particular focus on supporting biomedical research as an engine for development and the improvement of the lives of the world’s most vulnerable populations. Undoubtedly, Bill Gates deserves unanimous recognition for his role in improving global health among children and his notable contribution to the improvement of strategies for the prevention, control and treatment of the most common diseases. Hopefully, his current interest and direction will contribute to continued improvement in the surveillance of the leading causes of death among children and lead to better strategies for preventing such deaths.

[Quique Bassat is a researcher at the Barcelona Institute for Global Health (ISGlobal). He is currently working on the CaDMIA project at the Manhiça Health Research Centre (CISM) in Mozambique. ]