Death is still a taboo subject, even for medicine, and if it is a child’s the problem is even greater. ¿Is there something more difficult to digest?
Fortunately, in Europe this phenomenon is exceptional. In countries like Spain out of every 1,000 live births, only 3 will not reach 5 years of age. But nevertheless, In the poorest countries, death in childhood is much more common and infant mortality rates are unacceptably high.
Although it seems incredible, they exist today places in the world where 1 in 10 live births will die in childhood. It is difficult to think of a statistic that is more demonstrative of the inequities between the rich and poor world.
If we want to do something to improve this situation, we must start by focusing on these deaths, which in many cases are invisible to statistics.
In poor countries many children are born and die without ever being registered. Some call it “the invisibility scandal.”
Many die at home, outside the reach of the health system, and therefore without preventive or therapeutic measures at their disposal.
These invisible deaths seem to matter to no one, because few know they have occurred. Making them visible is not enough.
We must also understand why they occur and design health policies capable of preventing preventable causes and curing curable causes. That is where we fail miserably.
Anyone might think that knowing what someone has died of is easy. In Europe, if we get sick or our health is in danger, we can go to any hospital (there will always be one nearby). There they will not only be able to access our complete medical history, but they will also be able to determine very precisely what happens to us through a battery of tests and analyzes. Reaching a diagnosis is possible and easy.
If we die on the street, forensic medicine will be in charge of studying what happened to us with an autopsy. This is not an option, it is a legal requirement. Therefore, it is very difficult for someone in our environment to die and we do not get to know what has happened to him.
In the poorest countries, and especially in rural Africa, this is different. The methods available to investigate what someone has died of in these contexts are either unreliable or imprecise. On the one hand, there is the verbal autopsy, an interview with the relatives of the deceased weeks or months after death, aimed at gathering information through questions about what happened in the previous days. The responses are analyzed by a clinician or by a computer program.
How reliable will a method be based on what a relative without health qualifications reports about something that happened months ago? What medical knowledge do we ask of them in environments where a significant proportion of the population cannot even read or write? Although it may be useful to monitor trends in the main causes of death at the population level, this methodology is not very robust for the determination of individual causes.
In those cases in which patients have been seen in a hospital, we will have a little more information. Again, How accurate is the diagnosis in places famous for the shortage of doctors and tools? The only way to find out this is to compare the verdicts proposed by the clinicians who saw these patients before they died with the cause attributed by the reference method, which is the anatomopathological autopsy.
The results of this comparison are quite disappointing. Unfortunately, discrepancies are frequent and occur in up to half of the cases. Diagnostic errors (which in these settings often carry fatal risks) are plentiful. No matter how good we doctors think we are doing our job, If we do not have basic diagnostic tools to do it, we will be condemned to speculation.
Why not do autopsies, as would be done in Spain?
There are two main reasons: First, there is an overwhelming shortage of pathologists and trained personnel in Africa. If in Spain there is one pathologist for every 15,000 inhabitants, in Africa there are countries that do not even have one.
On the other hand, this practice is considered too invasive and bloody and has little acceptance. Although autopsies are the gold standard, and the surest way to find out the cause of death, they are an often unacceptable procedure, and therefore not feasible in these settings.
How We Create Minimally Invasive Autopsies
Faced with this dilemma, our team, which has been investigating the causes of death in the poorest countries for more than 20 years, developed in 2013 what we now know as a minimally invasive autopsy (MIA). It is a methodology postmortem of obtaining samples -with biopsy needles- of the most important organs of the body.
This method facilitates the removal of small cylinders of tissue from organs as important as the lung, liver and brainas well as blood and cerebrospinal fluid. Therefore, it simplifies its study and allows a much more accurate diagnosis.
By examining these samples under a microscope, we can know with certainty if the organ they came from was sick, healthy, or if some microorganism had infected the patient.
This way we will have a fairly complete vision of what was happening inside the body and, therefore, of what killed that person. All with hardly any visible marks on the body, a fundamental element for greater acceptability where a complete autopsy was not considered permissible. A very simple, but tremendously powerful idea that has revolutionized the surveillance of causes of death in the poorest countries.
Since our team validated the methodology (in a direct comparison with the full autopsy) the method has been adopted all over the world, and is used routinely in the CHAMPS infant mortality surveillance network present in Africa and Asia, where more than 2,200 have already been carried out. The data that have begun to be generated are changing the current paradigms about death and its causes.
Although difficult to scale at the population level, these autopsies offer the real possibility of generating data – now credible – on the diseases and pathogens that contribute the most to prematurely killing children.
Knowing what people die from is essential to be able to design health policies necessary and implement the appropriate measures to prevent these deaths. It is also essential to know how to better distribute the few resources available in health that these countries have, often below $ 100. per capita yearly.
Death can teach us a lot. Surely, from so many and so many premature, preventable and unnecessary deaths we can extract the appropriate lessons that help us avoid that the place of birth is the main determinant of the chances of survival.
*Quique Bassat is pediatrist and epidemiologist, ICREA researcher, Institute of Global Health from Barcelonto (ISGlobal)
Clara Menendez is ddirector of the ISGlobal Maternal, Child and Reproductive Health Initiative
Jaume ordi it is professor of the ISGlobto the
This article was originally published
you on The Conversation. You can see the original version here.
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