Assessing probable causes of death without death registration or certificates: a new science?

The study of mortality, with its measurement of numbers and death rates, has long been a priority for demographers. The study of causes of death and their role in public health is an area where collaboration between physicians and demographers has been particularly fruitful, as demonstrated in the research presented by Garenne & Fontaine in 1986. It was first published in French, (1) with a subsequent version in English which is extracted here. (2) The classification of causes of death is always a difficult exercise: difficult in developed countries where the registration of all deaths is relatively complete, necessitating 10 revisions of the International classification of diseases and causes of death; (3) more difficult in developing countries where often less than half of all deaths are registered. The deceased patients often received no medical attention, either because they lived too far from the health system or because the establishment of the cause was of no interest to anyone. In countries with incomplete statistics, Yves Biraud recommended, in 1956, the use of information supplied by the relatives of a deceased person, in an attempt to establish a "community diagnosis" of the cause of death. (4) The first simplified lists of causes of death for use in developing countries were published by WHO in 1978, (5) only six years before the study under review. A few teams of doctors and demographers had started to research the establishment of causes of death in the well-known "population laboratories" that provided a complete registration of vital events through longitudinal demographic surveillance: in Khanna, northern India, between 1955 and 1960; in Companigonj, Bangladesh, between 1975 and 1978; and in Santa Maria Cauque, Guatemala, and Narangwal, Punjab, between 1978 and 1982. The term "verbal autopsy" was first proposed by Arnold Kleiman and coworkers in a publication emanating from Narangwal in 1983. (6) Although the term is not used by Garenne & Fontaine in their article, it can be considered that they are among the "fathers" of this new technique, defined as "a procedure to exploit the information provided by the relatives of a deceased person to reconstruct the events and symptoms that preceded the death so as to deduct a medically acceptable cause, or causes, of the death". (7) During the following decade, several other research centres started to lay down experiments and theories about the assessment of causes of death by verbal autopsy, such as Matlab in Bangladesh, Niakhar in Senegal, Machakos in Kenya, and MRC Laboratories in the Gambia. The first international workshop to share experiences was organized by the Department of International Health of the Johns Hopkins School of Public Health in March 1989, (8) at which Garenne presented his standardized method developed in Morocco and Senegal. Five years later, a first workshop focusing on maternal deaths was convened by the London School of Tropical Medicine and Hygiene. (9) The work by Garenne & Fontaine came at the right time to demonstrate a favourable conjunction between demography and public health. It emanated from a study on the relationship between nutritional status and mortality of children under five years of age in Niakhar, a rural region of Senegal under demographic surveillance. This study of causes of deaths was first presented at a seminar on new approaches to the measurement and analysis of mortality organized in Sienna, Italy, in 1986 by the International Union for the Scientific Study of Population (IUSSP) and published in French as part of the proceedings. (1) It has been cited, in either French or English, in almost every subsequent publication on verbal autopsy. This paper represented an important step forward, because it came at a pioneering time when fellow researchers in the same area needed a bit of guidance and theory, particularly regarding the format of the questionnaire to be applied. …