Knowing the Causes of Death in Developing Countries: an Absolute Requirement to Reduce Mortality

[This article has been written by Jaume Ordi, Research Professor at ISGlobal, and published in Spanish in El Universal (México)]

Knowing the most frequent pathologies that affect a population and the diseases that cause the most deaths is of utmost importance for Health Ministries and other health-related institutions.  With this information in hand, they can decide where to allocate resources in order to have the maximum possible impact in improving the population’s health and life expectancy. Although these resources are limited in developing countries, they represent a considerable percentage of the national budget. In addition, there are hundreds of millions of euros that international agencies provide every year for the treatment and prevention of diseases in low and middle-income countries. Therefore, having precise information on the causes of death is of utmost importance given its impact on the economic development of a country.   

Unfortunately, a great number of people in developing countries (...) are born, live and die without leaving any record

The causes of death are known through mortality records that allow for the analysis of disease patterns and their changes over time, as well as the comparison of causes of death between populations. This information is exhaustive and universal in high-income countries, where the clinical autopsy is a valuable tool to improve the mortality records and provide conclusive scientific evidence when performed.  

In contrast, the mortality records in most developing countries are very limited or practically non-existent. Unfortunately, a great number of people in these countries- particularly those living in rural areas- are born, live and die without leaving any record, which is an unacceptable failure of our globalized society in the 21st century. Even though some developing countries do practice clinical autopsies, they are almost exclusively performed in large city hospitals and the information they provide cannot be extrapolated to the rest of the rural population.  

The causes of death are known through mortality records

The main source of information for causes of death in rural areas of developing countries comes from so-called verbal autopsies, a standardized procedure that allows obtaining an approximation to the cause of death by interviewing relatives, friends or care providers of the deceased person.  Thanks to these verbal autopsies, we know that there is a high frequency of infectious diseases in developing countries and a high risk of death during pregnancy, delivery and childhood. However, the weakness of the verbal autopsy lies in its lack of specificity and its failure to identify specific infectious agents. 

A group of scientists from ISGlobal has developed a minimally invasive autopsy protocol that can be performed in low-income countries

Over the last years, a group of scientists from the Barcelona Institute for Global Health (ISGlobal) has developed a minimally invasive autopsy protocol that can be performed in low-income countries. With this protocol, biopsies of the main internal organs (namely lungs, brain and liver) are obtained using needles less than two millimetres thick that leave practically no traces on the body, and is therefore more acceptable for the family.  Importantly, this protocol can be performed by specifically trained technical staff and is therefore highly appropriate for developing countries that lack specialized pathologists. Another major advantage of this method is its high level of acceptability among people living in geographically and culturally diverse countries such as Mali, Gabon, Mozambique, Kenya or Pakistan. 

We are currently finalising the analysis of the first 300 minimally invasive autopsies performed in Mozambique during the CaDMIA (Cause of Death using Minimally Invasive Autopsy) Project, funded by the Bill and Melinda Gates Foundation and that ended in 2015. The project consisted of taking samples using minimally invasive procedures, followed by a complete autopsy. The results show that the procedure is capable of determining the precise cause of death in more than 70% of the cases and that the highest accuracy is for infectious diseases, many of which can be prevented or treated with simple and effective methods. A notable feature of our protocol is that part of the samples obtained can be analysed with microbiology techniques, allowing for detailed information on the death-causing infectious agents. 

The results show that the procedure is capable of determining the precise cause of death in more than 70% of the cases

The preliminary results obtained with CaDMIA indicate that the minimally invasive autopsy can improve our knowledge on the causes of death and therefore significantly contribute to reducing mortality. In view of these encouraging results, the Bill and Melinda Gates Foundation has recently granted funding to a second project called CaDMIA Plus, whose main goal is to develop and refine the minimally invasive autopsy for the identification of causes of death among children under five years of age, new-borns and stillbirths. An added element in the new project that reflects the high expectations of this method is the creation of a training and research centre in minimally invasive autopsies that will contribute to encourage and harmonize post-mortem studies in developing countries. The new training centre will be jointly led by ISGlobal and the Central Hospital in Maputo, Mozambique, in a clear example of collaboration between both institutions and their ongoing commitment for North-South/South-North knowledge transfer.