News Even if they make it to a health Malaria deaths are the hardest to count post, persuading busy staff working in difficult conditions to fill in basic patient How do you count the number of people who die of malaria in sub-Saharan logs can be tough, especially if they African countries, where data collection systems are often rudimentary, and where view it as an administrative chore which childhood fever and other illnesses are typically attributed to malaria? prevents them from treating the sick or they have no paper or pencils to take In the early hours of the morning, particularly in subeSaharan Africa, down the details. Aurola Ngueve strapped her feverish where malaria is believed to claim most Then, analysts are often forced to daughter to her back and walked almost of its victims, the process is far more adjust and harmonize already quese three kilometres to a tiny Angolan govee complicated. And this process becomes tionable numbers in an effort to make ernment health post, a white concrete more problematic still with a disease like them internationally comparable or structure sitting incongruously amid the malaria which typically afflicts chile tally with other causes of death. mud huts of the village of Muinha in dren, whose immune systems are still But gathering mortality data on central Bié province. underdeveloped, and whose symptoms malaria is more problematic than In the rudimentary examination — fever, vomiting, aches and pains, most diseases. room, Aurola anxiously tells the Bulletin and diarrhoea — could be attributed Given that the burden falls on that 18emontheold Rosalina, who is to innumerable ailments. young children — an estimated 90% of screaming as a nurse “The major malaria deaths in Africa occur in chile takes a tiny blood same problem with malaria dren aged under five years — a principal ple from her finger, We need reliable is that it is very dife indicator of the trend in malariaerelated has had chronic diare ficult to measure its deaths recommended by the Roll Back rhoea for days. Fifteen malaria statistics to be burden, as it is so Malaria Partnership is allecause undere minutes later, Aurola able to target control unspecific and most five mortality, routinely measured in receives the dreaded, if resources and evaluate kids have parasites [in malariaeendemic countries by nationally not unexpected, news. their impact. their blood] in high representative communityebased demoe Rosalina has malaria. Allan Schapira, Coordinator in WHO’s transmission areas,” graphic and health surveys (DHS). Malaria is believed Global Malaria Programme. says Dr Kenji Shibuya, In its favour, this method should to be one of the Coordinator of the capture soecalled indirect, malariae chief culprits behind Health Statistics and related mortality — or how malaria cone Angola’s appalling child mortality statise Evidence team at WHO. tributes to child mortality by exacerbate tics. UNICEF estimates that one child Establishing “the burden” or in ing other common childhood illnesses, in four in this southewestern African other words establishing just how many by contributing to low birth weight country is unlikely to live beyond his people die of this disease is crucial in and generally weakening children as a or her fifth birthday. light of the Roll Back Malaria campaign result of repeated or chronic infections. Rosalina is one of the lucky ones. target to halve malaria mortality by 2010 At this health post, run by the Health and again by 2015 and the Millennium Ministry and supported by nongovee Development Goal to halt and reverse ernmental organization Médecins Sans the incidence of malaria by 2015. Frontières, she has been accurately Yet both the statistics on which diagnosed and prescribed medication. these goals stand and the methods for Her personal details, symptoms, diagnoe measuring progress towards them can be sis and treatment have been entered into called into question. a logbook, and the nurse is confident “The fundamental problem of that with the right care she will bounce malaria control was the lack of good back to health in a few days. baseline data,” Shibuya says, referring to But just how many children will slip the data against which changes in incie through the net? How many will never dence and the number of deaths can be be properly diagnosed, and how many measured. will eventually succumb to this mosquitoe Often the issue is not malariae borne disease which is, in theory, easily specific. Getting data on all diseases in preventable? If only we knew. developing countries is challenging bee In the developed world, where cause large sections of the population causes of death are registered, collecting never set foot inside a medical facility, Karen Iley mortality data is relatively straighte their ailments and deaths going largely Angolan mother Aurola Ngueve holds Rosalina forward. In developing countries and unexplained and unrecorded. while the child is tested for malaria. Bulletin of the World Health Organization | March 2006, 84 (3) 165 News As Bernard Nahlen of the Global precise longitudinal monitoring costly mosquito nets are working? And how Fund to fight AIDS, Tuberculosis and to implement and difficult for poor can they determine how much more Malaria told the Bulletin: “In children in countries to sustain, it often takes a long money needs to be spent on combating higheendemic areas, indirect, malariae time to collect and analyse enough data the disease? related mortality may be just as or even for a reliable estimate, while problems “We need reliable malaria statistics more important than the burden of in data availability and interpretation to be able to target control resources acute, direct malariaeattributable more make comparisons between subsequent and evaluate their impact,” says Dr tality — but it is even more difficult to estimates difficult. DSS are also typie Allan Schapira, Coordinator in WHO’s measure.” cally smallescale, and extrapolation to Global Malaria Programme. “As long To further clarify the picture, the wider continent needs to make use as the distribution of the problem is WHO recommends that specific, direct, of malaria risk maps. known and funding is available, the acute malariaeattributable mortality also Summing up the problem, Nahlen resources will be channelled to those in be tracked. This is done mainly through says that extrapolating malaria mortality need, provided that the delivery systems demographic surveillance sites (DSS) rates to the wider continent is “fraught can do the channelling. However, a gross where disease and deaths are continue with difficulties”. underestimation in a particular area may ously monitored in selected populations Malaria is such a nebulous disease cause insufficient funding of a given and cause of death is ascertained by that the chances of getting the numbers programme.” interviewing bereaved relatives. wrong are great, and this may adversely No one doubts that malaria places A synthesis of available data by affect decisionemaking. WHO and the US Centers for Disease a heavy burden on the countries that “We must have accurate mortality Control and Prevention (CDC) can least afford it. But to know just how and case data so we can evaluate proe published in 2005, showed that direct big a toll the disease takes and whether malariaeattributable mortality in sube grammes and see the effects of intere the projects that are currently in place Saharan Africa among children aged ventions,” says Angus Spiers, UNDP’s to fight it are actually working, requires under five years accounted for about Global Fund Malaria Advisor in Angola. more ingenuity and investment than 18% of all deaths in this ageegroup, or How will WHO and governments had perhaps been anticipated, when between 700 000 and 900 000 children. know if funding is headed to the right the Roll Back Malaria movement was However, even these “latest” figures areas? How will they know if intere initiated, Schapira says. O refer only to 2000. With surveys and ventions such as insecticideetreated Karen Iley, Lusaka Dr Roberto Becker, Regional Mexico’s quest for a complete mortality data set Advisor on Diseases Classification at PAHO in Washington, DC, explains On 1 November cemeteries across Mexico are packed with the living. Death has a special that although most deaths are logged place in Mexican culture, especially on the Day of the Dead — El Día de los Muertos. with a civil registry, the cause of death But while a culture that accepts death may smooth the task of collecting mortality data, — recorded in the certification process poverty is a major obstacle for Mexico in its quest for a complete data set. — is often missing. As part of the 1995 initiative, Becker travels to the countries in PAHO’s region to teach Mexico has been recording deaths in the 1980s, more than 90% of the dead health officials how to improve covere registers for more than 100 years, but it have been counted due to this switch age in quality data. was not until the 1950s that the country to a death certification “We don’t have developed a death certificate system. system. In the ’50s, 100% coverage. But “There are two moments when ’60s and ’70s mortale The problem we are very close,” people die [on paper],” says Dr Rafael ity data was only 70% Lozano, General Director of Information or 80% complete. In … is the gaps within Lozano says, citing at the Mexican Ministry of Health. the WHO European the country. The a study published “One is the certification of the death Region coverage is difference [in life in the Bulletin [2005:83;171–77] and the second is the registration. about 100%, while expectancy] between Before 1950 we only registered death in the WHO African that ranks Mexico without certification.” Region it is less than the poorest and among 23 countries Certification means that a doctor 10%.