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Why Did People Die? Unreliable Data Affect Research in Many Arab Countries

Death certificates in the Middle East are often inaccurate, two new studies have found, which makes it difficult to determine which causes of death researchers and public-health specialists should focus their efforts on.

The first study, published in the Journal of Forensic and Legal Medicine, pooled the findings of five individual research papers, which had recorded or mentioned inaccuracies in death certificates throughout the region.

It’s difficult to even determine how inaccurate Middle Eastern death certificates are. Different Arab countries have different error rates, according the study authors, but there isn’t enough data to reliably assign a specific percentage to each country. They estimate that most countries in the Middle East have an error rate somewhere between 15 and 40 percent. Even the error rates at the lower end of that spectrum are significant enough to undermine the precision of scientific research that depends on death certificates.

“I’ve moved past the stage of panic and shock,” says Mohammed Madadin, an associate professor of forensic medicine at Imam Abdulrahman Bin Faisal University in Saudi Arabia and one of the study’s authors. “I’m now trying to gather more proof and information to describe the problem so we can begin to solve it.”

Frequent Errors

The most common errors that Madadin and his co-researchers observed in the certificates included the failure to detail the time interval between the onset of the cause of death and the death itself, the use of layman’s language instead of precise medical terms, the lack of a doctor’s signature, and even the failure to list the cause of death itself.

He is also suspicious of the recorded cause of death in many cases. For example, he says it’s very common to write “cardiac arrest” as the cause of death without any supporting evidence. Cardiac arrest means loss of blood flow because the heart has stopped beating, but that should be listed as a mechanism rather than a primary cause, he says.

A second study, recently published in the World Health Organization’s Eastern Mediterranean Health Journal, backs up Madadin’s findings on a more local scale in Iraq. Scientists at Hawler Medical University, in Erbil, used death certificates to perform an audit on the death rate in the northern Iraqi city between 2007 and 2011. While they managed to determine the city’s death rate, they also found a troubling number of anomalies in the death certificates they examined.

“It’s also important for individuals themselves to know what genetic diseases they could need to look out for by actually knowing why their relatives died.”

Mohammed Madadin  
an associate professor of forensic medicine at Imam Abdulrahman Bin Faisal University in Saudi Arabia

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They discovered that approximately 28 percent of death certificates issued in Erbil during that time frame didn’t have any data on the cause of death, which led them to conclude that “the only use of a death certificate in Erbil is for the purpose of burial and legal issues,” and not to correctly record the cause of death.

Madadin says this issue of omissions and inaccuracies is well known to the doctors and government administrators who issue death certificates. “Either they’re not aware of the consequences or they just don’t care,” he says. “This has really big consequences.”

Others agree with him. “Providers are not well trained in filling in this information,” says Nahla Tawab, director of the Egypt branch of the Population Council, an international nongovernmental organization that does research on health and development issues.

Many researchers rely on death certificates as the key data source to study the patterns of diseases, which are critical to understanding how effective a given health intervention or policy may be. (See a related article, “Patterns of Disease Are Changing in the Arab World.”)

Such studies could also go some way toward explaining the gaps in our knowledge about the drivers of unequal life expectancy among different social groups in the Middle East, which researchers have previously lamented is extremely difficult to pin down.(See a related article, “Researchers Confront Puzzles About Risk and Disease in the Arab World.”)

Families Need to Know

“We need to know the effectiveness of our healthcare systems, to understand disease trends and to know which communities are most affected if we want to be strategic with budget planning and public spending,” says Madadin. “It’s also important for individuals themselves to know what genetic diseases they could need to look out for by actually knowing why their relatives died.”

Madadin is hopeful that as awareness of the problem grows, the reliability of data from death certificates will improve. He admits, however, that the accuracy of some research papers that rely on heavily death certificates, as many do, could be compromised.

Tawab doesn’t dispute that point, but adds that death certificates, however flawed, are often the only option and are definitely better than nothing.

“We should certainly be careful in accepting the results of those studies,” she says, “but sometimes they are the only source of data.”

To confront the problem, Madadin says there first needs to be greater awareness of the problem—especially among decision and policy makers. He’s also calling for more researchers to take on the subject to increase the amount of data on death certificate inaccuracies.

“We also need to know how solve the problem. It’s not straightforward, as every society is different,” he says. “But there are deficiencies in how we train doctors to write the certificates. They don’t get any formal training.”

He says that the Islamic tradition of quickly burying the dead probably is unlikely to be a barrier to improving the situation. “The physician will typically write the certificate immediately after death. Accuracy shouldn’t necessarily cause a significant delay.”


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