What Do Children Die of in Manhiça?

I work as a paediatrician and clinical researcher in Manhiça, a village in the south of Mozambique, one of the world's poorest countries. In this region, one out of every ten children will die before their fifth birthday, and a woman is as much as 30 times more likely to lose her newborn child than in our part of the world. These chilling statistics are silently confirmed by many of the mothers we work with daily in our hospital. So, why are these children dying? What information do we have about the causes? The answer is desperately discouraging: we have absolutely no idea.

It can only be described as an important failure of our global society that in the 21st century a substantial proportion of the people in the world are born and live with no official record of their existence, a blatant violation of a basic human right, and even worse that they may die without ever being seen by a medical practitioner. In Manhiça, children are born without birth certificates and die without death certificates.

 More than half of the deaths occur in people’s homes, far from any health centre or hospital, probably because almost two-thirds of the 25 million Mozambicans have no access to health care. This lack of access, along with the fragility of the overburdened and often understaffed national health system, also dogged by a lack of motivation and means, frequently creates insuperable barriers to medical care.

In this situation, doctors also face enormous challenges. Now, without wishing to complain about my workplace, the fact is that without good diagnostic support (and how often in this respect do I recall my dear and much maligned Spanish public health system), it is extremely difficult to be sure of the cause of a patient's death, especially in an epidemiological context where infectious diseases, such as malaria, HIV and tuberculosis, are rampant. Unfortunately, our understanding of the causes of many of the deaths we witness is poor, or even worse, wildly inaccurate. In affluent countries, a physician who needs answers can order an autopsy, but here that is not an option. With fewer than a dozen pathologists in the country trained to perform autopsies, it is not hard to understand why not. Besides, people in rural communities have a very low acceptance of such invasive procedures, even though they may also feel the need to know why their loved one died.

For all these reasons, we need to prioritise the development of new diagnostic methods for accurately identifying cause of death—methods that can be used wherever death occurs, whether in a simple hut made of mud and straw or a rural health centre. Such methods involve obtaining tissue samples that can be analysed for infectious pathogens or changes in key organs that might explain the patient’s death. We will only be able to improve our statistics on cause of death when these more acceptable and minimally invasive techniques can be applied by personnel with only a low level of training. Above all, without more accurate data, we will continue to work in the dark with scant information about why children die in places like Manhiça, and it will continue to be enormously difficult to plan health programmes and prioritise the allocation of the scarce funds available to ensure that they are used in the areas where they are most needed.

Quique Bassat is a paediatrician and clinical researcher in CRESIB, a Barcelona Institute for Global Health research centre. He is currently living in Manhiça, where he is conducting a study to validate a new technique for minimally invasive postmortem diagnosis to improve the diagnosis of cause of death.