Can death or mortality rates be a country's health indicator?
Shams El Arifeen: Death is an outcome or a consequence. Mortality rates depend on many things. Many patients are admitted to hospital with pneumonia and there are questions about the fatality rates. That is, how many people have pneumonia and how many of them are dying?
The objective is to ensure that people don't die of pneumonia. If there are too many fatalities, that means there is something wrong in the treatment. Mortality rates indicate the state of health in a country. If child mortality rates are high, that means the child treatment system is poor. That is why death of mortality rates can be considered a health indicator.
When it comes to definitions, what do we understand by mortality rates?
Shams El Arifeen: Death is an incident. And mortality rates are the trend or recurrence of that incident.
Let's start with child mortality. The child mortality rate is defined as the number of deaths per 1000 live births of children up till the age of five. The calculation is done per 1000. This indicates the number of deaths within a specific age limit.
The calculation of maternal mortality is different. Maternal mortality rate is how many women among 10,000 die during childbirth. This is calculated by the death of a woman within 42 days of giving birth. The age of the mother is not taken into cognizance here.
Deaths can be calculated by a 'crude death rate'. This will take into account the number of people dying per every 1000 in a year. These include infants, children, mothers and people of all ages. This will consider all the causes of death -- various diseases, drowning, etc. The 'crude death rate' includes all ages and all causes.
Prothom Alo :
How do we get the figures of deaths every year in Bangladesh? How reliable are the figures?
Shams El Arifeen: There is a figure regarding the number of deaths in Bangladesh every year, but that is an approximation. It is not a specifically calculated number.
Registration is the ideal way to record the accurate number of deaths. This is death registration. Many countries have this registration system. Every death is recorded there. At the end of the year, a figure is taken from those records.
Bangladesh has a death registration system, but as adequate registration is not done, it is not possible to get an estimate of the number of deaths at the end of the year.
Our estimated numbers come from various survey data. There is no national survey.
Some sort of statistics is availed from MICS or BDHS. That provides information on the deaths of a specific population. The death of people from all over the country cannot be ascertained by means of MICS or BDHS. MICS or BDHS is not carried out every year.
In that sense, the comparatively more regular data can be availed from SVRS. SVRS has representation of the entire country. According to the latest SVRS, 5.6 persons per 1000 die on the country every year. Like BDHS and MICS, now SVRS' data is nationally representative. That may be the credible figure, closest to the actual numbers.
Another calculation is the Inter-Agency Mortality Estimation. The World Health Organisation, World Bank, UNICEF, UN Population Division give a different sort of death calculation. Their numbers are based on data modelling. But in this case I am not in favour of using any model, I would take the estimated figures.
Death is inevitable, but we cannot just resign ourselves to this fact and do nothing. First we have to see who are dying at a premature age. If children are dying more, then we will have to look into why child mortality is high
Why is it so important to have the accurate number of deaths?
Shams El Arifeen: There are two major reasons why it is important to have the accurate death figures.
From the mortality rate we can understand how many people are dying compared to the population. There is a huge difference between one death in a thousand and 10 deaths in a thousand annually. If the death rates are high, the question of preventing these deaths arises. It can then be discerned which age group has the higher number of deaths. If child deaths are higher, then the question arises as to why so many children are dying. If the question is about the cause of deaths, then there is the matter of action. But if you don't have the number of deaths, they a correct initiative can't be taken to lower these deaths.
The other reason is related to rights. Just as birth registration is a right, death registration is also every person's birthright. This right is established by means of accurate figures, that is, the registration of each and every death. If there is a registration system, then a person's right is established even after death.
As I said earlier, fatality rates give a picture of the country's state of health.
Prothom Alo :
In order to project that Bangladesh's socioeconomic and health state has improved, it is said that people's average life expectancy has increased. What does average life expectancy mean? How is this calculated? How is it related to death or mortality rates?
Shams El Arifeen: If an infant is born today, how long is the child likely to live? That is called life expectancy at birth. This is not a common average, but a probability. If today's circumstances and the risk of death remain same always, then the probable years that the infant born today may live, is its life expectancy.
This calculation is a bit complicated. First of all the number of living persons in a certain area and their ages is collected as well as the number of people who died over the past year and their age at the time of death. Based on this data, the mortality rate of people of various ages is calculated.
A life table is drawn up on the basis of these figures where the probability of a group of people to remain alive at the end of every year is calculated. The probability of that group to remain alive is placed in an equation and the average life expectancy is determined.
This average life expectancy figure basically is related to mortality rates. If the mortality rate of people of various ages in the society decreases, then life expectancy will increase. In particular, if a country can reduce its infant and child mortality rates, then that country's life expectancy increases the fastest.
So life expectancy is an excellent means of determining a country's overall health. It gives us an idea of the health system and helps us take important decisions to improve public health.
The issue of death is not raised much during discussions on health. Don't you think death should be discussed?
Shams El Arifeen: Death should be discussed with the question of how to reduce premature deaths. In the final sense, death can't be prevented. But it is possible to prevent premature deaths.
Deaths can be reduced in the case of maternal deaths, child deaths. And we are doing that here in our country. At one time so many mothers would die, but that has reduced. At one time many children would die before they reached five years of age. That had decreased. But still many mothers and children are dying.
We have to pinpoint the shortcomings. There are some countries which have lower maternal mortality than us. Similarly the child death rates are lower. We have to see what they are doing that their maternal mortality rate has fallen. It means that maternal mortality can be prevented.
Our experience is that, alongside education and economic development, we have reduced child mortality by means of certain social initiatives, improving nutrition and the Expanded Programme on Immunisation. Child mortality can be reduced further by taking up new initiatives or expanding the initiatives that are considered successful.
Prothom Alo :
That means there are preventable deaths. Can be have some examples?
Shams El Arifeen: At one time we would see many people dying of cholera. We don't see that anymore. It has been possible to reduce deaths due to contagious diseases like cholera. Many contagious diseases have been reduced by means of vaccines, drugs and people's awareness. We don't hear of hundreds of people dying of cholera anymore.
But there has been an increase in deaths due to high blood pressure, kidney diseases, cancer, strokes, COPD and heart diseases. But it is possible to reduce the number of deaths due to these diseases. There are two ways. Firstly, preventing these diseases. The government has a lot of responsibility in this regard. People's awareness is also essential to ensure this disease does not occur. Secondly, people should receive the correct treatment in time when the disease occurs. Around 60 per cent of the deaths that occur in the country now are due to non-contagious diseases. This rate can be decreased. If this can be done, then life expectancy will increase. There are instances of this around the world.
Prothom Alo :
What can be done to reduce deaths?
Shams El Arifeen: Death is inevitable, but we cannot just resign ourselves to this fact and do nothing. First we have to see who are dying at a premature age. If children are dying more, then we will have to look into why child mortality is high.
Secondly, of which disease or cause are people dying more? If it is seen that more people are dying of heart ailments, then measures to prevent heart disease must be taken. People have to be conscious and take all sorts of measures so that they don't get heart diseases. There are drugs, technology, workforces, ambulances, hospitals, etc, for the purpose. If people suddenly are assailed by a heart attack, they should be able to reach hospital speedily, the hospital must be ready to provide treatment. Correct treatment reduces deaths related to heart diseases.
Heart diseases must be reduced in the shortest possible time with accurate treatment. Financial paucity is an obstacle. This applies to strokes and many other diseases too. The bottom line is, these are preventable.
No matter what preventive measures are taken by people, the society and the state, death is inevitable. So then what?
Shams El Arifeen: There are two things to be done. A record must be kept of how many deaths are taking place and the causes of death. There must be death registration. We talk strongly about birth registration, but not so much about death registration.
Secondly, death certificates must be issued. The dead person may not benefit from the death certificate, but even so it is essential. It is essential for the country, for the family.
Prothom Alo :
But not much is said about death certificates and people aren't too interested either. Why?
Shams El Arifeen: It must be kept in mind that every death should be taken into account. The state institution must be informed. There must be a system where the state is informed of this.
There are certain problems in this connection. Firstly, the family of the deceased concentrates on laying him or her to rest. They are not concerned about any death certificate and do not feel the need for it. Secondly, many feel that collecting a death certificate is a hassle. Also, people are not even aware that such a thing exists.
Prothom Alo :
What would you say should be done in this regard?
Shams El Arifeen: Birth certificates come to use in many ways. It is required to get admitted into school, to make a passport, to apply for a job, etc. A birth certificate is a person's right.
It must be kept in mind that there is arrangement for death certificates too. But the state system to provide this must be simplified. The existing system must be reformed and made easy. Death certificate is a right. People's awareness must be increased in this regard. A demand for this must be generated. The family must be made liable. Before death every person will know that after they pass away they will have a death certificate. That is a birthright.
* This interview appeared in the print and online edition of Prothom Alo and has been rewritten for the English edition by Ayesha Kabir