More than half of the world’s population are born and die without any record of their existence, and these individuals invariably live in the world’s poorest countries where the burden of disease is the highest. In many parts of Africa, Asia and South America, someone can go through life without ever seeing a doctor and when they die they will be buried without any clear understanding of their cause of death. The lack of such information means that it is impossible to accurately determine the important health priorities in a community – if you don’t know what people are dying from you cannot know what to do to prevent premature death and sickness. For anybody to go through life without any official record of their existence has been described as “a scandal of invisibility” and “the single most critical failure of development over the past thirty years.”

Systems for measuring mortality in poor countries simply do not exist because they are too expensive to implement on a large scale. As such, a number of smaller scale, localised population ‘surveillance’ systems have been established in many poor countries over the last 10-15 years. These systems are a useful surrogate for more widespread surveillance activities, but the methods used lack standardisation and a strong evidence base, thereby making comparisons of mortality patterns over time and between different areas difficult.

This thesis evaluates, develops and refines methods of measuring mortality in localised population surveillance settings in Ethiopia, Vietnam and Burkina Faso. A large part of this work focuses on an innovative method of determining cause-of-death through a process of verbal autopsy whereby the relatives of the deceased person are interviewed to gather information on the signs and symptoms of the deceased shortly before death. This information can then be used to derive probable causes of death in settings where Western-style death certification and pathological examinations are very rare or non-existent. The thesis also examines how such data could be used for monitoring important changes in population health by describing a missed humanitarian crisis caused by famine in rural Ethiopia and evaluating a way in which surveillance data could have been used for early detection of the impending crisis.

This work contributes to the understanding of mortality surveillance methods and demonstrates that localised population health surveillance systems have the potential to contribute substantially to developing healthcare systems in resource-poor countries. Ultimately, the value of such systems lies not just in counting all deaths but in making all deaths count.

Edward Fottrell can be reached at the Department of Public Health and Clinical Medicine, Epidemiology and Public Health, mobile phone: + 46(0) 70-293 43 23, e-mail:

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