The Next Page / Footprints in Africa

Former Peace Corps volunteer Julia Fraser writes about birth, death and disease in an African nation that can't accurately track any of the three.


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In the United States, we take for granted vital records that tell us about relatives long passed. Children draw their family trees in the classroom. We subscribe to online genealogical databases.

It's a different story in developing countries such as Senegal, where vital records are hit or miss. Instead of reliable data on life expectancy, mortality and causes of death, there are only vague estimates, which hinder public-health research and potentially affect levels of aid to impoverished countries.

And the difference between existing in the public record or only in the memory of your immediate family can be a half-mile-long journey down a sandy road. Such is the case of baby Oussmane and his father, Sekho.

Sekho's wife, Sadio, did what she was supposed to do. In February, her water broke while she sat under a tree in her village in central Senegal. Sekho and her sister-in-law, Khady, helped her onto a charette, a wooden flatbed cart pulled by a horse, and took her to a health post a half-mile away.

PG map: Senegal
(Click image for larger version)

Most village women still give birth in their homes with the assistance of a midwife, who typically has no formal medical training. But Sadio had attended talks at the government-run health post and had checkups there with the nurse, who stressed the importance of delivering her child at a health facility in case of a complicated birth.

Because Oussmane was born at the health post, his arrival was officially recorded. A day later, Sadio and her healthy baby returned to the village and were greeted by Sekho and his family. Within a week, the village gathered in the couple's compound for Oussmane's kutiyo (Mandinka for a newborn's Muslim naming ceremony).

Days later, Sekho was dead.

He fell ill one night and, within two days, died in his bed. He was too ill to travel to the health post. Following Muslim practice, the funeral took place within 24 hours. There was no official record of his death. There was no autopsy. No cause of death was determined or recorded. There was no death certificate.

Family members attributed his death to "sickness" or, when asked to be specific, "malaria," which they know to be the most common killer in rural Senegal. Here, there are no gravestones even to mark the resting places of the dead.

Ideally, Sekho would have visited a health post for diagnosis and treatment. If his sickness was beyond the post's capabilities, he would have been sent to a hospital, about 6 miles away, to see a doctor trained as a general practitioner. From there, he could have been transferred to the regional hospital in Kaolack or the national hospital in the capital, Dakar.

However, travel to the health post can be difficult or impossible during the rainy season, when the road floods. Villagers often rely on traditional medicine and healers, which they view as providing less expensive, but comparable, treatment. If Sekho had died after being treated at a health post, his death would have been recorded and the information turned over to the state.

Sekho was young, probably in his early 30s. He didn't have a birth certificate, as village births typically aren't recorded. But he did have a state identification card with an estimated birth date.

His mother, Aissatou, proudly showed me his card, bearing his photo and a birth date that would have made him 33 at the time he died. Aissatou then showed me her card, which showed the usually-smiling woman wearing a bright head scarf and a serious expression. The birth date made her 40, only seven years older than her deceased middle child.

Senegal has a centralized health system but still struggles to get trained personnel into remote areas, distribute medications beyond the regional capitals and produce reliable local reports. Such shortcomings affect the quality of data that are important to public-health research and used to determine levels of domestic and foreign aid.

According to 2009 World Health Organization data on Senegal, for example, the probability of dying between the ages of 15 and 60 is about 3 in 10 for men and about 2 in 10 for women.

WHO researchers generally collect data on deaths using national death-registration systems. Death statistics for nations without usable death-registration data, such as Senegal, are estimated. WHO mortality data for high-income countries have a 1 percent margin of error, while the margin of error on data for sub-Saharan African nations such as Senegal ranges from 15 to 20 percent.

Wide-ranging estimates extend to data on malaria, the leading cause of death in most areas of Senegal and the target of considerable foreign health spending. In 2000, for example, WHO recorded 165,933 reported cases of malaria in Senegal, but noted that "trends in cases may be influenced by reporting effort rather than underlying trends in disease."

The data are further limited by the reality that developing countries do not always have laboratory tests used to identify malaria. When rural health posts in Senegal run out of easy-to-use diagnostic tests, it can be months before the shelves are restocked due to a lack of funds or the fragile supply chain. When cases must be diagnosed without a test, WHO notes, "there is considerable overdiagnosis of malaria."

Sadio's future is uncertain.

After the funeral and days of wailing (the shrieking women make after a death is announced), she resumed some of her normal activities, such as cooking and gardening. She may stay in her husband's village or return to her family's, depending on how she feels and whichever might be the better option for supporting herself and her three children.

By delivering Oussmane at the local health post, she has made sure his birth was properly recorded. The infant also has a health card listing his vaccinations and vital statistics.

He is a tiny addition to a more accurate statistical profile of his nation. Unlike the father he never knew, Oussmane will be counted.

opinion_commentary

Julia Fraser (julia.d.fraser@gmail.com) is a writer from Penn Hills. She lived with Aissatou, Sadio, Sekho and Oussmane while working as a Peace Corps volunteer in Senegal for more than a year.


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