UNDER SCANNER: A body brought into a morgue for postmortem.

Every sixth person who dies in this world is an Indian. So India is the best laboratory for anyone seeking the causes of human death. Little surprise, then, that a study of the causes of human deaths over 16 years from 1998 to 2014 is looking at a million deaths in India.

Called a million-death study, work on it starts now. It will use the sample survey system of the Registrar General of India and cover a population of 1.14 crore, roughly corresponding to the population of a metropolitan city like Delhi. The other partners in this $2 million survey of deaths are the Indian Council of Medical Research and the University of Toronto’s Centre for Global Health Research (CGHR). Writing on the ambitious enterprise, Prabhat Jha of the CGHR explains, “There is a dearth of reliable and accurate information on the causes and distribution of mortality in developing countries where 46 million out of the total 60 million deaths world-wide occur. India has about 9.5 million deaths a year. But over three quarters of these deaths occur at home and more than half of these do not have a certified cause.”

However, the study on the causes of deaths has sparked off criticism of its purpose and its utility. Says Dr C.R. Soman of the Health Action by People, an NGO in Thiruvananthapuram, “In most cases, the causes of death given by relatives is old age or similar monosyllables and thus authenticity is doubtful.” Soman is himself conducting a smaller prospective study on causes of death in Varkala, a small town in Kerala.

Besides, he says, the study’s findings would relate to the whole country, whereas each state needs detailed insights into the causes of death there. He also maintains that the study will not throw up any new information and the expected data are almost a foregone conclusion ? that the cause of death in India is no longer infectious diseases but those like vascular diseases. “The precision attempted is no precision at all. For the study is dividing causes into five broad categories of vascular deaths, TB and other respiratory diseases, cancer infection, diabetes, peptic ulcer and external causes,” says Soman. “This will not add to the existing knowledge of the causes of death,” he continues. “This exercise at best will give the people involved an enhanced academic reputation for which the infrastructure of the Registrar General is being used,” he adds.

He also argues that the component in the study involving collection of blood samples indicates that blood-based genetic epidemiology is being contemplated. The study has the risk of making genetic material being made available to the outside world, he warns.

Zulfiqar A Bhutta, professor and head of the department of paediatrics at Karachi’s Aga Khan University, too says the goals of the study are too limited to achieve any good. He agrees with Soman on the need for district-specific or state-specific information in order to influence policy making. It should also take into account maternal mortality and childhood mortality to throw light on malnutrition, he says. In an article published in the Public Library of Science, Bhutta says, “The study has the potential of addressing priority issues in public health if it is modified by increasing the sample frame and by making it district specific. Besides, it must include maternal and new-born health indicators.”

The Registrar General of India whose bureaucrats are co-authors of the study decline to reply to questions from the media. While D.K. Sikri, Census Commissioner and Registrar General of India, declines to comment, R.C. Sethi, Deputy Director General in the office of the RGI, says that no blood tests are being done. He adds that the study will contribute to collecting authentic information on death using techniques such as verbal autopsy.

Verbal autopsy is a method experimented with by researchers trying to ascertain the causes of death in studies in south India. The first such experiments were done in five states in April 2002 and their results were reviewed by an expert panel of WHO in June 2002. The early review found that even basic (one day) training decreased the proportion of deaths for which there was only a one-word narrative from 50 per cent to five per cent.

Questions are asked for specific symptoms and signs for the death of a person and then conclusions are arrived at rather than going by the one-word reply of relatives on the cause of death. For adult deaths, there is a list of signs and symptoms used by the RGI surveyor to obtain more detailed information about the cause of death. The symptom list is used as a filter to define additional probing questions that should be asked if the respondent mentions a particular symptom during the verbatim account of death.

The written narrative details the following information: associated designs and symptoms in chronological order; duration; whether the onset of illness was sudden or gradual; the type of treatment, if any treatment was received; details of hospitalisation prior to death; the name and location of the hospital; the duration of hospitalisation; the history of similar episodes and treatment given; abstract information related to the illness prior to death from available investigation reports, and death certificate or discharge summaries. Each interview lasts 30 to 45 minutes.

Sethi also points out dual reporting will be used to ensure authenticity ? two independent surveyors would monitor selected households, with a part time enumerator (commonly a teacher) making monthly visits and a full time RGI surveyor visiting a household every six months. Field reports will be emailed to trained physicians who then arrive at a conclusion on the cause of a death.