Mortality beyond emergency threshold in a silent crisis- results from a population-based mortality survey in Ouaka prefecture, Central African Republic, 2020.

BACKGROUND: The Central African Republic (CAR) suffers a protracted conflict and has the second lowest human development index in the world. Available mortality estimates vary and differ in methodology. We undertook a retrospective mortality study in the Ouaka prefecture to obtain reliable mortality data. METHODS: We conducted a population-based two-stage cluster survey from 9 March to 9 April, 2020 in Ouaka prefecture. We aimed to include 64 clusters of 12 households for a required sample size of 3636 persons. We assigned clusters to communes proportional to population size and then used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. In addition to the mortality survey questions, we included an open question on challenges faced by the household. RESULTS: We completed 50 clusters with 591 participating households including 4000 household members on the interview day. The median household size was 7 (interquartile range (IQR): 4-9). The median age was 12 (IQR: 5-27). The birth rate was 59.0/1000 population (95% confidence interval (95%-CI): 51.7-67.4). The crude and under-five mortality rates (CMR & U5MR) were 1.33 (95%-CI: 1.09-1.61) and 1.87 (95%-CI: 1.37-2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death were malaria/fever (16.0%; 95%-CI: 11.0-22.7), violence (13.2%; 95%-CI: 6.3-25.5), diarrhoea/vomiting (10.6%; 95%-CI: 6.2-17.5), and respiratory infections (8.4%; 95%-CI: 4.6-14.8). The maternal mortality ratio (MMR) was 2525/100,000 live births (95%-CI: 825-5794). Challenges reported by households included health problems and access to healthcare, high number of deaths, lack of potable water, insufficient means of subsistence, food insecurity and violence. CONCLUSIONS: The CMR, U5MR and MMR exceed previous estimates, and the CMR exceeds the humanitarian emergency threshold. Violence is a major threat to life, and to physical and mental wellbeing. Other causes of death speak to poor living conditions and poor access to healthcare and preventive measures, corroborated by the challenges reported by households. Many areas of CAR face similar challenges to Ouaka. If these results were generalisable across CAR, the country would suffer one of the highest mortality rates in the world, a reminder that the longstanding "silent crisis" continues.

Internet searching produces misleading findings regarding violent deaths in crisis settings: short report.

Donor and agency priorities are influenced by a variety of political, social, and media-related forces that can have a profound impact on response and resource provision. We have attempted to assess how well internet searches articulate the span of violent death rates for five current "crisis" settings. In three graduate classes (2 public health, 1 information science) at US universities, during a four month period in 2017-2018, we asked approximately 60 graduate students to conduct an internet search to determine which of five countries had the highest and lowest "violence specific mortality rate": Venezuela, Syria, Yemen, Central African Republic (CAR), or Mali. Students were divided into groups of three, and within each group explored this question by three approaches. Many graduate students in all groups could not determine the relative rates, especially which country had the lowest violence specific mortality rate. Of the 34 searches that identified a highest violent death rate country, 27.5 (81%) concluded it was Venezuela, followed by Syria (4.5; 13%), Mali (1; 3%) and CAR (1; 3%). Of the 26 searches that identified a least violent death rate 21.5 (83%) reported either CAR or Mali, followed by Yemen (2.5; 10%) and Syria (2; 8%). Aside from lack of data on CAR and Mali, students were perplexed about whether to include suicides or executions in the measure. This resulted in almost half of all inquiries unable to estimate a highest and lowest rate among these five countries. Where conclusions were drawn, it is likely the internet drew students to the opposite conclusion from reality. There are several reasons for this discordance, such as differing categories of violent deaths as defined by the World Health Organization, and search engine algorithms. It is probable, however, that larger issues of connectivity of individual societies with each other and the outside world are playing a profound role in the deceptive results found in this exercise. This insight emphasizes the internet's under-reporting in the world's most poor and remote locations, and highlights the importance of primary data collection and reporting in such settings.

Erratum to: When violence becomes endemic.

The article "When violence becomes endemic", written by Leslie F. Roberts, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 03 August 2017 without open access. The original article was corrected.

Commentary: Ensuring health statistics in conflict are evidence-based.

The author argues that measuring mortality in conflict settings is fraught with limitations which mostly result in under-estimation of mortality. Some recent publications on this subject have been based upon convenient surveillance processes, or even press reports. The author calls for vigilance against such studies and argues that war related surveillance-based mortality estimates should include measures of sensitivity and representativeness.