He asks the young man who came in from the fields to answer his questions.
What is your name? What is the age? Religion? Marital status? What grade did you leave school in? Do you own a bike? Mr. Alpha taps the young man's laptop on his knees.
Did anyone die in your home in the last two years?
The young man says that he is my mother.
Mr. Alpha asked her name and then asked if she was sick. How long? Is it a case of Fever? Is it rising or falling? Vomiting? Is it diarrhea? Is that a word? Did she see a doctor? Do you want to get medication? Do you have pain? How long did the pain last?
Ms. Kamara's son is reticent at first but is soon able to tell the story of the last few weeks of his mother's life. Mr. Alpha taps away until every detail has been entered in the software of a public health survey. He snaps his laptop closed and applies a sticker to the wooden shutter of the front window of the house as he reiterates his sympathies and moves on to the next home.
Mr. Alpha and three colleagues will use an electronic verbal autopsy to gather the details of every death that took place in the village of Funkoya since 2020. The project's head office is in the town of Bo, a few hundred kilometers to the east. A physician reviews the symptoms and describes the cause of death.
It's necessary here because only a quarter of deaths in Sierra Leone are reported to a national vital statistics registry system, and none of the deaths have a cause assigned. The life expectancy here is just 54 years, and most people die from preventable causes. Because there is no data about the deaths of its citizens, the Sierra Leonean government plans its programs and health care budget based on models and projections that are, ultimately, only best guesses.
There are a variety of reasons that families don't report the deaths of their loved ones. They can't afford transportation or pay a fee for the death certificate if they are far away from the registry office. It may be that they have never heard of the practice, the state has very little presence in their lives. The dead are buried behind their homes or in small village plots, and the local chief might make a note in a ledger, the contents of which never travel out of the village. Sierra Leonean hospitals don't automatically share their death records.
Sierra Leone is not an exception. Vital statistics collection in the developing world is weak. While progress has been made in recent years in terms of birth registration, nearly half of the people who die around the world each year do not have their deaths recorded.
There is no incentive in death registration, according to the Center for Global Health Research in Toronto. He pioneered these kinds of efforts to count the dead in India two decades ago, and it has shown that the model will work anywhere, and has helped bolster a government eager to root its policies in evidence and hard.
The topic of vital statics registration is important for understanding public health and socio-economic inequality. New attention has been given to the topic. The debate over how many people have died from the coronaviruses has become political, and in countries such as India lower death counts have served the agenda of national governments hoping to downplay the role of failed pandemic policies.
Stephen MacFeely is the director of data and analytics for the World Health Organization.
There is a fierce debate among epidemiologists about whether Africans are dying of Covid-19 at the same rate as people elsewhere in the world, and if they are not, about what might be protecting them.
Efforts to reduce preventable deaths are complicated when countries don't know who died. The budget of Sierra Leone is based on models provided by the W.H.O., the World Bank and other agencies that project the number of people who will be killed in the country each year. These models are built on global estimates and draw on dozens of studies and individual research projects, which can do a reasonably good job of estimating the larger picture but are sometimes far less accurate at the national level. Even though all three countries are in Africa, the Malaria data that came from the two other countries isn't necessarily going to be accurate for Sierra Leone.
He said that countries should not rely on a university in North America or the W.H.O. to make decisions.
When you count the dead, you get information that you didn't expect.
The first COMSA study looked at the households of 343,000 people. Dr. Ansumana refused to believe the discoveries until they had been checked and rechecked, a number of different ways.
The dean of the college of community health at Njala University said that he got convinced with facts and evidence.
Malaria was the first big surprise. It was found to be the biggest killer of adults in the country. In medical school, Dr. Ansumana was taught that people who survived childhood had immunity that prevented them from taking their own lives.
He said that most of the health care workers in Sierra Leone believed it. The data showed that there was a U-shaped curve with high numbers of young children and low numbers of young adults, but then the numbers rose again in people over 45.
Maternal mortality was the second shock. 510 of every 100,000 women die in childbirth, which is a staggeringly high rate, but still only half of what the United Nations bodies reported for Sierra Leone. Dr. Ansumana said that the finding was a relief for the government because it showed that resources were being poured into making childbirth safer for women and babies.
The second round of the national survey is looking at the health impact of Covid-19.
One of the countries trying to figure out how to make certain that more deaths are counted is Sierra Leone, which is working on reforms to its civic registration.
Many of the fixes are simple and don't cost much, according to the leader of a program that aims to boost health data collection in low and middle-income countries.
It starts with changing the death certificate to collect usable information on who died and why, and training doctors to be aware of why a specific cause of death is important.
She said that the data may be collected by a national interior ministry and not shared with a health ministry. It doesn't make sense for data to be moldering in ledgers. It should be easy for people to register a death.
A routine collection of verbal autopsies for all who die outside of a health system is another step. This involves training people at the community level to try to collect information on every death in order to try to provide basic primary care in low-income countries.
Ms. Ellis said that the other steps cost very little. When Data for Health joined up with the government there in 2015, the number of deaths that included a recorded cause rose to 34 percent. The cause-of-death reporting system that was introduced in Peru made death information available in real time, and it reported some of the highest Covid death rates in Latin America.
Information captured by new death registration systems has quickly been translated into health policies. When it was discovered that road accidents were the top cause of death in the country, the government quickly introduced safety protections in the worst-affected areas. In India, the number of people dying of snakebite exceeded the W.H.O.'s estimate for the entire world, and antivenom was made available to more primary care centers in heavily affected areas.
Many countries are eager to transform what they learn from death statistics into policy, but others are hesitant. He said that some people view higher Covid death counts as an indictment of their responses to the epidemic.
He said that the W.H.O. encourages countries to treat vital statistics data the same way they treat other forms of infrastructure.
This is part of managing a modern country.
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