Khadija Magardie
One of the most crucial ways of moni-toring the health of the nation is through mortality statistics. In a chapter on “Health status and determinants” in the South African Health Review, the authors argue that statistics need to be compiled more rapidly and the current disease notification system “needs attention”.
The South African Health Review is the most comprehensive overview of developments affecting health in South Africa today. Published annually by the Health Systems Trust, it combines detailed information on health status and health care with in-depth analysis of policies and practices affecting the provision of health services in South Africa.
Currently South Africa faces the challenge of “the simultaneous triple burden of infectious diseases related to poverty, emerging chronic diseases and injuries”. HIV/Aids in particular, say experts, is likely to double overall mortality rates and “undermine gains in child survival and halve life expectancy over the next few years”.
But there have been problems in this regard. Deficiencies in reporting causes of both natural and unnatural deaths have meant that information on Aids-related deaths is merely speculative.
According to the review, the government has made extensive efforts to improve the collection of death statistics and determine the main causes of death, particularly for children. But the most recent statistics available are from 1995. The data suggests that the major causes of death in infants are, firstly, conditions that occur during the perinatal period, secondly, low birth weight and, thirdly, diarrhoea. Deaths attributed to HIV/Aids number a mere 3,2%, the second-lowest cause of deaths within this subgroup.
However, a footnote reads that the top 10 causes of death for infants under the age of one year have “almost certainly changed in the intervening years, particularly due to HIV/Aids”. The impact of HIV/Aids on mortality figures is footnoted in an identical fashion under a variety of categories, including causes of death of adolescents at “high risk” for contracting and dying from HIV/Aids.
The authors suggest that tracking causes of death can be done by improving the available epidemiological database. The systems available are the state census and vital registration data, the Demographic and Health Survey, the cancer registry, and the newly formed National Injury and Mortality Surveillance System (NIMSS).
Though they provide useful information about the health of the nation, the review says, the current statistics have yet to achieve the desired level of accuracy and coverage. It is for this reason that there has been criticism of HIV/Aids mortality figures in particular subgroups. In almost every category external causes are reported as the main causes of mortality.
For the first time in almost a decade the “who, what, when, where and how” of fatal injuries in South Africa is being documented. Despite their importance, details about injury-related deaths have been glaringly absent from the country’s national death statistics since 1991.
NIMSS ensures that injuries that cause death can be tracked and monitored. The project is based at 13 urban state mortuaries, in five provinces. In collaboration with forensic patho-logists and state forensic chemistry laboratories, NIMSS records all fatal injuries within its catchment area. It registered up to 25% of all deaths in the country during 1999. Because of the locations of the mortuaries, the system does not represent the rural areas.
This has particular consequences for the single-biggest cause of homicides in South Africa; firearm-related violence. The first annual report of NIMSS, launched by Gun-Free South Africa in Johannesburg recently, found that firearms overshadowed all other external causes of non-natural deaths. People with guns are killing more people in South Africa than the most commonly thought cause of mortality, motor vehicle accidents.
When it comes to gunshot injuries, the need for a statistical profile is vital. In the United States, health workers are required by law to report all gunshot injuries to the police, a situation that does not exist here.
Last year the head of the trauma unit of the Red Cross Children’s hospital in Cape Town, Dr Sebastian van As, called for new laws to force doctors and nurses to report and for police to investigate all gun-shot injuries. Van As, who also testified at the parliamentary hearings on the Firearms Bill, said this was necessary not only to stem the rising tide of people, especially children, falling victim to guns, but also to monitor the use of illegal firearms.
The Red Cross Children’s hospital would know 10 years ago it used to see fewer than 10 children with gun wounds a year; now it sees an average of 50 a year. The NIMSS study found that, from the age of five, more youngsters are killed in firearm-related homicides than in homicides involving stabbing, beating or strangulation.
The report registered 14829 fatal injuries and found that homicide, accidents and suicide were the leading causes of non-natural deaths. About 12% of deaths were undetermined. Furthermore, it registered that males constituted 79% of all injury deaths, with the leading manner of death being homicide. The number of cases a month trended upwards across the year for all manners of death, except suicide.
NIMSS aims to expand its geographical and case coverage until all injury deaths are included in “an ongoing system for the epidemiological surveillance of fatal injuries”.