Understanding Verbal Autopsy through experiential learning, by Dr. Ameena Mumthaz M. C.
During my MBBS studies, while reading the forensic medicine paper, I found the concept of verbal autopsy fascinating. I imagined what it would be like to determine the cause of death by analyzing the history gathered from close relatives. However, I had several questions: Why do we need to conduct a verbal autopsy? Why can't we simply perform a standard autopsy? Why is it not widely practiced in urban areas? Although I had read about it in books, I wanted to gain practical experience. Little did I know that the answers to my questions would come from my experience here in Kalahandi.
Kalahandi is where I completed my tribal health fellowship in 2022-23. It is one of the poorest and most underdeveloped districts in India. The area where I work, Thuamul Rampur, is predominantly tribal. The villages are located in valleys and hills within the forest. The infrastructure is either nonexistent or poor, with no proper roads or transportation. Some villages are so deeply nestled in the forests that one might not even believe they exist. Life there is vastly different from the mainstream; the challenges are unique, creating a completely different world.
A few months ago, our field animator informed us about the death of a young lady in one of our project villages. When we visited her home a few days later, we met her mother-in-law and began conversing with her. Since it was during my initial months here, my understanding of the language was limited. With the help of our clinic staff and the Swasthya Sathi (A tribal woman
from the village who is the point of contact from the community who is trained in the very basic healthcare practices ), we started inquiring about the young lady. Initially, we asked her to recount the day of the death and if she noticed anything unusual. She provided a vague account, saying that the young lady went to work every day, but one day she experienced body pain, seemed tired, and then passed away the next day. There was no history of fever, cough, infection, bleeding, injury, or trauma—nothing at all!
Within the next half hour, people began gathering—relatives, neighbors, and children. Everyone had their own version of the story, and it seemed to be going nowhere. We then started asking a few leading questions. We inquired about where she worked, what kind of work she did, and finally, someone mentioned that she had difficulty drinking water the day before she died. We probed for more details and learned that she had hydrophobia and aerophobia, leading us to conclude that the cause of death might be rabies. Following this, we conducted a quick screening of others in the village for any symptoms and sought information on any rabid animal history, but there were none. We also advised the villagers to inform the clinic in case of any unusual behavior of animals.
Had the incident occurred in an urban setting with a robust healthcare system, the patient would have received timely treatment, and the cause of death would have been detected and recorded. Verbal autopsy describes the causes of death at the community level or population level in areas where there is no medical certification of deaths or it is not yet well-established. Verbal autopsy serves as a valuable tool for countries to obtain the information needed on non-medically certified community deaths to strengthen civil registration and vital statistics (CRVS) systems and provide critical health data for evidence-based health policies and plans. (2)
In these trial villages where health care services and facilities are non-existent or relatively poor,also where the community's approach to life and health-seeking behavior is quite different, obtaining an autopsy to determine the cause of death is often not feasible. First, you may learn of a death only after several days. Second, the community's health-seeking behavior is typically low, making the existence of medical records unlikely. Out of respect for the community and their mourning period, visits can only occur after the funeral ceremonies are complete.
The process involves asking questions about how the death occurred, what transpired leading up to it, the individual's previous health status, and the symptoms experienced before death. Essentially, one would pose leading questions to rule out possible causes of death. Verbal autopsy is usually conducted by a trained health worker.
After collecting information from various reliable sources, the different accounts are compiled and analyzed by doctors to infer the cause of death. It is crucial that data on causes of death are
available, reliable, timely, and collected to create a robust evidence base for strategic health interventions and policies.
If a community experiences a death from an infectious cause, conducting a verbal autopsy can help identify the cause and implement measures to reduce transmission and mortality. Many low- and middle-income countries struggle with inadequate death registration and reporting of medical causes due to years of underinvestment. This creates a significant gap in data, as approximately half of all deaths worldwide go unreported, with most occurring in these regions.
Today, verbal autopsy (VA) is a well-established surveillance method used primarily in research settings and as part of large household surveys to assess disease burdens within populations. At the macro level, VA has the potential to help close gaps in data availability and usage, guiding policy implementation, evaluation, and investment in health systems.
References:
1.Thomas LM, D'Ambruoso L, Balabanova D. Verbal autopsy in health policy and systems:a literature review. BMJ Glob Health. 2018 May 3;3(2):e000639. doi: 10.1136/bmjgh-2017-000639.PMID: 29736271; PMCID: PMC5935163.
2.https://www.who.int/standards/classifications/other-classifications/verbal-autopsy-standards-as certaining-and-attributing-causes-of-death-tool
Bio :
Dr. Ameena Mumthaz M.C. is a Tribal Health Fellow (2022-23 Cohort) from the Sathya Swaraj Society, an NGO focused on comprehensive primary health care for the tribal population of Thuamul Rampur in the Kalahandi District of Odisha, India. Ameena also worked with Médecins Sans Frontières on a project in Mizoram that focused on the primary health care needs of cross-border populations from Myanmar, as well as on an advanced HIV project in Patna, India.
Support Ameena's Masters program for Global Health Delivery at the Harvard University. Learn more HERE.
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