Prabhat Jha: Counting the Dead and Describing the Causes is the 'GPS' to Global Health

"We are in the midst of an extraordinary epidemiological transition, with big declines in childhood but also adult mortality". This is how Professor Prabhat Jha, expert in epidemiology at the Dalla Lana School of Public Health in Toronto, introduced the first 2016 Global Health Lecture, a series of conferences organized by ISGlobal and its allied centre CREAL in which worldwide experts address different global health issues.

However, the majority of global deaths do not have a certified cause. This is due to the fact that, in middle and low income countries, most people die in their households, so the causes are not known. For example, 40% of dead African children never made it to a health facility. During his lecture, that took place January 19^th in the Centre Esther Koplowitz in Barcelona, Professor Jha presented the main results of The Million Death Study that was conducted between 1998 and 2014 to determine the causes of premature death in India. For the study, government staff was trained to ask standard questions in houses reporting a recent death. These "verbal autopsies" were then analysed by a team of more than 300 physicians in order to determine the causes of death.

The results show that the distribution of deaths (by causes and ages) between homes and hospitals is very different. They also show that the child mortality in India has decreased by 40% and that most deaths due to pneumonia and diarrhoea occur in the poorest districts, which permits to do focused and targeted interventions. Nevertheless, there is an extremely worrying gender bias, where girls in India have a four to five-fold higher risk of dying than boys in all districts, both rich and poor.

Concerning adults, the preventable causes of death have also decreased (malaria, HIV but particularly tuberculosis), while cardiovascular deaths have increased, reflecting the ongoing urbanization trend in the country. Suicides are much more frequent among young people in India, as compared to western countries. Tobacco-associated deaths are also on the rise, and will soon reach levels similar to those in the West. Epidemiologists estimate that one decade of life is lost to tobacco. But it is never too late to quit: if you stop at age 40, you may still recover 9 of those 10 years.

The expert concluded that The Million DeathStudy confirms the need to consider deaths outside hospitals and to adopt a population-based focus. Verbal autopsies can and must be improved, but must be performed at a national level, at a low cost (less than 1 USD per house in India's case) and organised internally if they are to be sustainable. The aim now is to scale-up this type of studies to other countries, such as Ethiopia and Mozambique.