The Incredible Challenge of Counting Every Global Birth and Death

As in many other parts of the globe, a count of births and deaths among rural Colombians is a vital public health measure. It's harder than you think.

Dr. Diana Hidalgo, left, and Dr. Paola Rosero delivering a newborn girl in Mocoa, Colombia.Credit...Juan Arredondo for The New York Times

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Jeneen Interlandi

March 29, 2023

On a good day, the roads around the Jerusalen - San Luis Alto Picudito indigenous reservation in Putumayo are dangerous. In some places they are made of mud and gravel, but they can be narrower than a small pickup truck. After a storm they may even give way to rivers. The roads twist, turn, and bump continuously. Marleny Mesa decided to avoid traveling during the most difficult weeks of her pregnancy when she felt like everything was cardboard and that it hurt just to stand or sit. It was necessary to skip the checkups in Villagarzon because it could take up to two hours to reach. Marleny was not overly concerned. Early in her pregnancy, a nurse told her that her blood tests were good and everything looked fine. Marleny, a midwife by profession, knew that the risk of making the trip was greater than not attending a few doctors' appointments.

She could not shake her feeling that something was wrong, even though it was the last days of pregnancy. One thing was that she could barely breath. Her anxiety and physical discomfort was at an unmanageable height. Andres Noscue called an ambulance. No ambulance arrived for hours. He had tried to find a vehicle to take her to hospital. He also called Marleny’s sister Omaira to pray over her stomach. This seemed to work. Marleny began to breathe more evenly, and about a week later she gave birth to a tiny boy with jet-black hair and curious, soft eyes. The couple named Eliad.

Marleny was sure he would be perfect. But her mother, who is a retired midwife insisted the placenta had a hint. She said it was much too large, and Eliad too small. This was probably because there was not enough room for him to grow in her womb. His grandmother believed he may need an incubator. Marleny was sure he was healthy, but she and Andres decided to take him to Villagarzon to have a checkup.

It was harder than expected. The hospital in the area would not let the baby into the building until he obtained a civil registration or identification number. This was impossible to obtain without a birth record, and the hospital couldn't provide one because the child had been born at home. The nurses instructed Marleny to Andres to go the the registrar office. The registrar sent Andres to the hospital. A different nurse then told them to go to the notary instead. It was now almost noon. Andres' family would need to pay more for their room and board if they missed the only bus that was going back to San Luis. They went home.

They returned to the registrar a few days after, but this time his instructions were more complex and different. He said they would need to bring two witnesses, including those from the reservation, as well as several documents, such a document containing the blood type of the child and one that shows the care Marleny had received during her pregnancy, to prove he was indeed their son and born within the borders of the country. Andres claimed that the man was suspicious and asked questions he hadn't asked before. Andres said to me on a hot July afternoon, as we sat under the covered wooden porch of his family. They didn't think the child was ours so we returned home. They planned to go back to Villagarzon to sort out the situation as soon as possible. Eliad began to develop a horrifying rash, with blisters all over his face and head. He also started gasping for breath.

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The family returned to Villagarzon a third time. Marleny was at the hospital waiting for Andres while he went to the notary. He was lucky this time: a clerk at the hospital put him in contact with Leydi Rodrguez, a community worker working with Colombia Rural Vital. This is one of many initiatives launched by Vital Strategies and Bloomberg Philanthropies in an effort to improve death-and-birth registries throughout the world. According to the organizations, two billion people lack birth certificates and about half of the 60-plus million deaths that happen each year are not recorded. This failure has many and often dire consequences: Families such as the Noscues struggle with accessing the rights and benefits that citizenship provides. The government struggles to allocate resources and formulate health policies that are evidence-based. A wide range of identity crimes, from election fraud to child trafficking, are permitted to flourish.

In low-income countries in Africa and Southeast Asia, the problem of inadequate registrations is more pressing. It is not just a problem in those areas. Birth and death registration in Colombia is particularly sporadic among Indigenous and Afro descent communities. The national government has a limited presence, and registrars, notaries, and other officials tend to apply rules arbitrarily. Colombia Rural Vital was established to simplify and democratize the process.

Rodriguez, a petite woman of mid-30s with a plucky earnestness, raced to the office as soon as the clerk called. She asked Andres several questions about Eliad and entered his answers in an app on her tablet. In less than an hour, she certified the birth of Eliad and its parentage. She explained that Andres still had to fill out a few forms but Eliad now had a certificate of birth and could go straight to the doctor. Andres brought the birth certificate to the hospital. The hospital's news was much less comforting. Eliad was suffering from a serious bladder infections and possible birth defects. Doctor told them that the child was in a very bad condition. The couple should've brought him in earlier.

Data theft is a lucrative industry in the world's richest nations, and their protection has become a major concern. It can be hard to imagine the opposite, a complete lack of identifying information. Data scientists claim that the undercounting is widespread. The consequences are many and serious, and the recent past is full of missed opportunities to fix this problem.

147 countries rallied in support of the Millennium Development Goals more than 20 years ago. The bold plan was a bold initiative by the United Nations to reduce extreme poverty, combat childhood mortality, and eradicate infectious diseases such as malaria and H.I.V. Critics claimed that officials from the United Nations, and other organizations, had little idea of the conditions in the countries they tried to assist. They couldn't say if maternal mortality was on the rise or falling, how many people had malaria or how quickly tuberculosis spread. Chris Murray, former director of the World Health Organization, and other researchers described in a 2004 article the estimates made by the agency as'serial estimation'. In 2004, the World Health Organization's former director of evidence, Chris Murray, and other researchers described the agency's estimates as'serial guessing.

The underlying problem, however, was not obscure. Many low- and middle-income countries did not have working systems of civil registries or vital statistics. This meant that a large majority of births, and about one third of all deaths, were not counted. Instead of developing these systems, health officials relied on a jumble of surveys, computer models, and censuses that only provided crude estimates for specific illnesses. Critics argued that effective birth and death registers would paint a much more accurate picture. The surveys and censuses, however, were quicker and cheaper. With a list of disease-specific programmes now competing for resources and a whole system reform taking a backseat, the critics argued.

It's a Catch-22 situation, says Prabhat Jaha, professor of global healthcare at the University of Toronto. When you lack good data, you use clever mathematical models. Global funders and politicians may be wrong, but they think that because of the data available, it is okay to invest in less robust solutions.

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In 2015, The United Nations launched a bold initiative to fix this problem. This initiative aimed to ensure that births, deaths, and all other vital statistics would be recorded by 2030. This effort has failed to achieve its objectives after seven years. Philip Setel is a medical anthropologist and demographic expert who leads Vital Strategies' civil-registration project. He says that this failure has been the most significant in development over the last 30 years. Not only because the problem is widespread or underappreciated, but also because its impact is so broad. Bangladeshi widows cannot secure land rights and survivor benefits if they don't have the ability to register their spouses deaths. Rwandan street kids are unable to access schooling or the legal economy due to a lack of valid birth certificates. Young girls in Southeast Asia are unable to escape forced marriages because they lack the documents necessary to prove their age or identity. Stephen MacFeely is the director of data analytics and statistics at the World Health Organization. He says that this situation is 'disastrous'. This is an important, basic metric. We still haven't a handle on these two bookends.

These shortcomings were difficult to ignore during the pandemic. As scientists tried to understand how dangerous the coronavirus was, or how long a wave would last, elected officials, and their constituents were transfixed by maps, graphs, and the striking exponential growth curves. The crisis's symbols may have created a sense of control and understanding, but the truth remained elusive. Like the Millennium Development Goals (MDGs), at least a part of the issue was a matter of baselines. MacFeely explains that it is impossible to contact and trace people you do not know are there. You can't properly allocate vaccines, or know how severe a variant is, if don't have a count of the people who are affected.

Covid's true toll of death remains unknowable three years after the pandemic. The World Health Organization estimated that the death toll was 2.5 times higher than previously reported in May 2022: 15 million instead of 6 million. Scientists estimated that India's death rate from Covid had probably increased six-fold since the initial report. In a 2021 article in the journal eLife, the authors noted that there were also large differences between what government officials said and what independent analysis suggested in Belarus, Egypt Nicaragua, Russia Tajikistan Uzbekistan, and other countries. A certain amount of this undercounting was intentional and political. The lower the death toll, the more impressive a leader's pandemic reaction looks. Not all of it. For most of the pandemic, death counts in sub-Saharan Africa were low. Death registries in this part of the globe are particularly weak. Scientists say that it is unclear if these countries were spared from Covid or if thousands of deaths simply were not reported. Chris Murray, director of the Institute for Health Metrics and Evaluation, University of Washington School of Medicine, says that we will eventually find out. It's amazing how much uncertainty exists on such a topic that is actually very important.

Time is running out to strengthen our data systems. As the pandemic fades, other pathogens - mpox measles and influenza - are creating new havoc. Scientists say we could soon be facing multiple pandemics due to global warming. Tom Inglesby is the director of Johns Hopkins Center for Health Security. He says that protecting others will be our only option to combat these attacks. "Especially those who are the most vulnerable or least capable of protecting themselves." Counting them is the first step in understanding their lives, what causes them to die and how they live.

Marleny is a descendant of midwives, and she had already given birth to four children. However, she couldn't recall ever having taken an infant to hospital. She was confused when doctors in Villagarzon said that Eliad would need to be moved to a larger facility in Puerto Asis - a city located two hours away. She became furious when the nurses at Puerto Asis snatched the baby out of her arms, and whisked it off to intensive care without any explanation. Why would it be beneficial to separate a baby from his mother? Why couldn't she go to the I.C.U. Why couldn't she go to the I.C.U. She was told by a nurse to return to the reservation, as her baby would still be there. She was told by another nurse that she could return during visiting hours and breastfeed the baby if she wished.

She says that the next morning she found Eliad, who was cold, wet and covered in vomit, in an ICU. He had turned purple. He was crying. Marleny was desperate to get him home. She thought that if he were to die, it was better if he died where she could take care of him. Marleny was finally told by a doctor why the baby needed to stay. He required an incubator, antibiotics, and at least several weeks for him to heal.

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The couple spent the weeks in Puerto Asis with family, using their savings for personal expenses and hospital fees. They also bought diapers and other items. Marleny was only allowed to visit her baby during visiting hours. She couldn't help but think that he could have been spared from all of this suffering had the doctors at Villagarzon not refused him in his early weeks.

Edna Margarita Valle was not surprised by the experience of the Noscues. She is a lead coordinator in Colombia's National Statistics Department, DANE. Valle, who is based in Bogota, spends most of the year traveling to remote communities only accessible by boat or plane. She has encountered people in their 60s, 70s, and 80s who had never been issued a legal ID. She has met scores of families who have had similar experiences to the Noscues. She showed me a video when I visited her in July. In it, a family from La Guajira, across the country, described their four-hour motorcycle journey with a newborn. The registrar then sent them away. She said, 'It is the norm. The registrars are there for a long time and treat the place like it's their private business. Families are forced to pay for birth certificates which is a document that should be a human right.

National Civil Registration