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The coronavirus disease 2019 （COVID-19） has been a global epidemic for more than three years, causing more than 6.9 million deaths. COVID-19 has the clinical characteristics of strong infectivity and long incubation period, and can cause multi-system damage, mainly lung damage, clinical symptoms of acute respiratory distress syndrome （ARDS） and systemic multiple organ damage. The SARS-CoV-2 virus is still constantly mutating. At present, there is no global consensus on the pathological changes of COVID-19 associated deaths and even no consensus on the criteria for determining the cause of death. The investigation of the basic pathological changes and progression of the disease is helpful to guide the clinical treatment and the development of therapeutic drugs. This paper reviews the autopsy reports and related literature published worldwide from February 2020 to June 2023, with a clear number of autopsy cases and corresponding pathological changes of vital organs as the inclusion criteria. A total of 1 111 autopsy cases from 65 papers in 18 countries are included. Pathological manifestations and causes of death are classified and statistically analyzed, common pathological changes of COVID-19 are summarized, and analytical conclusions are drawn, suggesting that COVID-19 infection can cause life-threatening pathological changes in vital organs. On the basis of different health levels of infected groups, the direct cause of death is mainly severe lung damage and secondary systemic multiple organ failure.

Abstract Background The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. Methods The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. Results Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. Conclusions There is a need to supplement the pioneering “Three Delays Framework” to include focusing on continuity of care and the “Four Critical Connection Points”: (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. Trial registration NCT01911494, Date Registered 30/07/2013.

Abstract Background Malaria contributes substantially to the persistent burden of child deaths in sub-Saharan Africa. Accurate and comprehensive malaria mortality data are crucial to monitor the progress in reducing malaria incidence and mortality. Verbal Autopsy (VA) ascertains the cause of death despite its limitations leading to misclassification errors. Minimally Invasive Tissue Sampling (MITS) is being conducted in some settings as an alternative to Complete Diagnostic Autopsy (CDA). The present study examines the validity of malaria-related deaths comparing VA diagnoses with those obtained through MITS and/or CDA. Methods A comprehensive literature search for original studies in English language using Ovid MEDLINE, Ovid Embase, CINAHL via EBSCO, Scopus, The Cochrane Library via Wiley, Google Scholar and searching the MITS Surveillance Alliance papers was carried out. The reference period was January 1, 1990–March 31, 2024. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adopted. Results Among 71 articles identified in the databases, 21 matched the eligibility criteria. Qualitative syntheses showed that malaria Cause Specific Mortality Fractions (CSMFs) across various studies ranged from 2 to 31%. Plasmodium falciparum was mostly responsible for these deaths and the most common complications were anaemia and cerebral malaria. The sensitivity and specificity of the VA validation studies ranged from 18.4% to 33% and from 86.6% to 97%, respectively, and there was a high level of misclassification for both InSilico and Expert Algorithm VA for malaria compared to MITS. The overall concordance rates between MITS and CDA diagnoses ranged from 68 to 90%, with the highest concordance seen in deaths due to infectious diseases and malignant tumours. Clinical data increased diagnostic coincidence between MITS blind to clinical data and the gold standard CDA by 11%. Conclusions The comprehensive review finds that MITS demonstrated better accuracy compared to VA in diagnosing malaria-attributed deaths, particularly in hospital settings. The high specificity of malaria in VA diagnosis suggests population-based estimates of the proportion of deaths due to malaria are broadly plausible.

This data note provides details of the development of a Verbal Autopsy (VA) dataset produced with the South African Population Research Infrastructure Network (SAPRIN) drawing on datasets from health and socio-demographic surveillance sites’ (HDSS) ‘ covering a population of over 250,000 in two rural provinces in South Africa for the period 2012-2019. The purpose of the data set was to refine an analytical tool within VA, which provides unique information on care seeking and utilisation at and around the time of death complementary to that of medical cause of death. On an individual basis, the dataset includes demographic data, probable cause of death data, and data on care seeking and utilisation at or around the time of death drawn from longitudinal population cohorts. The purpose of this publication is to describe both the dataset and methods in formatting and processing the data for other researchers who may be interested in similar data. The data described in this paper are available to be requested from the respective HDSS repositories.

Drowning is the death caused by asphyxiation due to fluid blocking the airway. In the practice of forensic medicine， it is the key to determine whether the corpse was drowned or entered the water after death. At the same time， the drowning site inference and postmortem submersion interval （PMSI） play an important role in the investigating the identity of the deceased, narrowing the investigation scope, and solving the case. Based on diatoms testing， molecular biology， imaging and artificial intelligence and other technologies， domestic and foreign forensic scientists have done relative research in the identification of the cause of death， drowning site inference and PMSI， and achieved certain results in forensic medicine application. In order to provide a reference for future study of bodies in the water， this paper summarizes the above research contents.

Introduction/Objective. Autopsy represents the gold standard for determining cause and mechanisms of death. With this paper, the authors wanted to acquaint colleagues with our experiences while performing autopsies of COVID-positive deceased patients. Method. The study included total of 12 autopsies related to COVID-19 infection, performed in our forensic pathology institution, from which one autopsy of suspected patient and 11 autopsies of confirmed COVID-positive patients. Confirmation of infection was obtained by antemortem polymerase chain reaction analysis of oropharyngeal and nasopharyngeal swabs and by postmortem swabs taken from upper airways and lungs. Results. In five cases, cause of death was directly attributed to COVID-19 infection. In two cases cause of death was due to heart attack, in two cases due to gastrointestinal hemorrhage, in one case due to multiple injuries, in one case due to trauma complications and in one case due to gunshot injury. Conclusion. Large number of autopsies in which cause of death has been established to be other than COVID, along with importance of these cases for litigation, strongly emphasizes the importance of forensic autopsy of COVID-positive deceased. If adequate personal protective equipment is used, there should be minimal exposure risk to virus remaining in body tissues.

In this paper is analised mortality of population from two main diseases in the World. Its heart diseases (cardiovascular diseases) and carcinoms. Analysis is performed on base of demographic factors like: age, sex, race, ethnicity and religion, influence of migrations, difference in mortality between willage and city, influence of socio—economics status, profession, hygiene, habits of populations, specially nutrition on appear of desease. In paper is given brief history of disease, incidence and rate of mortality per regions and countries, including Serbia. Mortality and dinamic from different types of cancers has been analised. Influence of epidemilogical transition on alter in rates of mortality of cardiovascular diseases and carcinoms.

Abstract Background Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. Methods This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. Results A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10–27%) and severe preeclampsia/eclampsia (10–24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7–33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. Conclusion The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.

Abstract Background Despite attempts to apply standard methods proven to work in high-income nations, nearly all civil registration and vital statistics (CRVS) systems in low- and middle-income countries are failing to achieve adequate levels of registration completeness or produce the high-quality vital statistics needed to support better health outcomes and monitor progress towards the 2030 Sustainable Development Goals. This suggests that, rather than simple technical issues, these countries are facing additional or different systemic challenges, including duplication of roles and responsibilities, inefficient methods of data collection, and a reluctance to change. Applying process management Process management is a valuable tool that strengthens the production of vital statistics by providing a visualisation of data flow from start to finish. It helps identify gaps and bottlenecks in the process, allowing stakeholders to work collaboratively to find solutions and target interventions. As part of the Bloomberg Philanthropies Data for Health Initiative at the University of Melbourne, 16 countries were supported in mapping the varied processes required in registering a birth or death. Comparative analysis exposed several limitations in the design of CRVS systems that hinder their performance — from ‘passive’ systems, to overly complex and fragmented system design, through to poor collaboration and duplication of efforts. Conclusions The experiences from Myanmar, Papua New Guinea and Rwanda reported in this paper illustrate the benefits of process management to improve CRVS. While these three countries are at different stages of system development, each uniquely benefited. Process management is a useful tool for all CRVS systems, from the most rudimentary to the most developed. It can strengthen CRVS systems and improve the quality and completeness of vital statistics, resulting in more robust, reliable and timely vital statistics for health planning and better monitoring of the 2030 Sustainable Development Goal agenda.

Abstract Black esophagus is a rare medical condition, characterized by a circumferential blackish discoloration of the distal part of the esophageal mucosa, abruptly ending at the gastroesophageal junction. The etiology is multifactorial since patients suffer from multiple comorbidities. While the mortality rate specifically linked to black esophagus is only around 6%, the mortality rate linked to the underlying comorbidities amounts to 32%. A series of five cases is provided in which black esophagus was an unexpected discovery at autopsy. Black esophagus is generally considered being a challenge to the forensic pathologist. There are often no other major gross anomalies found at autopsy and information about the patient’s medical history is not always available, which complicates a correct assessment. We present a review of the literature on black esophagus, limited to reports on deceased patients. The reviewed publications are divided into autopsy and endoscopy series to correctly compare the causes of death. The aim of this review is to identify a possible divergence in causes of death in autopsy and endoscopy series and additionally to analyze the causes of these differences to enable better assessment and interpretation of black esophagus at forensic autopsies. This paper emphasizes the importance of a minimal knowledge of the victim’s comorbidities and medical record and the use of toxicology and postmortem biochemistry analysis as a valuable tool in investigating the cause of death in the setting of black esophagus.

Introduction/Objective Postmortem examination has a significant role in evaluating the quality of health care. The objective of the paper is to analyze the cause of death as determined by postmortem examination in patients who had undergone emergency hospitalization and had subsequently died within 24h, as well as the factors that contributed to the fatal outcome and correlation with available clinical data. Methods the analysis included autopsy reports and protocols, as well as clinical data from medical records and autopsy referrals during the three year period (2018-2020) for patients who had undergone a postmortem examination at the Insitute of Pathology, Medical Faculty, University of Belgrade. The correlation between the clinical diagnosis and postmortem findings was evaluated using Goldman criteria. Results the patients analysed were predominantly male (52/90; 58%). Women were statistically significantly older than men (p=0.024). The most common clinical diagnosis was cardiovascular disease (32.2%). The majority of the patients reported experiencing the first symptoms a few hours before seeking medical help (80%). The majority of the patients were being treated for chronic disease (80%) before hospitalization. The immediate cause of death determined by postmortem examination was most commonly heart failure (38/90, 42.2%). The most common clinically unrecognised causes of death include: bronchopneumonia (8/90), myocarditis (3/90), acute ischemic lesion/acute myocardial infarction (3/90) and bowel infarction (3/90). Conclusion the correlation between clinical and postmortem findings is very important because it enables the discovery of diagnostic and treatment errors and promotes new knowledge crucial for medical advancement.

BackgroundThe accurate attribution of death in oncologic patients is a difficult task. The patient’s death is often attributed to his or her underlying cancer and therefore judged as cancer-related. We hypothesized that even though our patient’s cancers were either advanced or metastatic, not all patients had died simply because of their cancer.MethodsA total of 105 patients were included in this retrospective analysis. Patient data were collected from digital and paper-based records. Cause of death was assessed from death certificate and compared to the medical autopsy reports. Discrepancies between premortem and postmortem diagnoses were classified as class I and II discrepancies.ResultsOf 105 patients included, autopsy consent was obtained in 56 cases (53%). Among them, 32 of 56 were palliatively sedated, and 42/56 patients died cancer-related as confirmed by autopsy. The most common cause of death by autopsy report was multiorgan failure followed by a combination of tumor and infection, predominantly lung cancer with pneumonia. Here, 21/56 cases (37%) showed major missed diagnoses: seven cases showed class I, 10 class II, and both discrepancies. The most commonly missed diagnoses in both categories were infections, again mainly pneumonia.ConclusionsCancer was the leading cause of death in our study population. A quarter of the patients, however, did not die due to their advanced or metastatic cancers but of potentially curable causes. We therefore conclude that it is important to consider competing causes of death when treating palliative cancer patients. In a palliative setting, the treatment of a potentially curable complication should be discussed with the patients and their families in a shared decision-making process. From our experience, many patients will decline treatment or even further diagnostics when given the option of best supportive care.

Background: Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. Objective: To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns. Design: Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death. Results: A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths. Conclusions: This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis.

“Karoshi” originates from Japan’s economic take-off period in the 1960s and 1970s. It is generally believed that overwork lead to the accumulation of fatigue, which triggers the outbreak of potential diseases, and results in sudden death. Karoshi causes great harm to both the community and families because it occurs primarily in 30 to 60 year old young adults. Japan put Karoshi into the category of industrial injury for the first time in 2001 and started to undertake a series of studies in the sociological and pathological fields. However, there is a tremendous gap in the forensic pathological diagnosis domain. In China, research on Karoshi started from the 1990s and is closely related to the reform and opening up policy as well as economic development. According to the incomplete statistics, 600 thousand people die from overwork each year in China, the highest in the world. Karoshi has become one of the most serious social problems in China at the present stage, thus a systematic study in the sociology and forensic pathology fields is urgently required. This paper summarizes the past and present status of Karoshi, and puts forward the problems that need attention during the judicial expertise of Karoshi from forensic pathology perspective.

Proteomics has become one of the hot topics in modern life sciences. Its application prospects have been confirmed in clinical medical research, such as the discovery of new disease biomarkers, identification of disease-related proteins, and development of new drug targets. However, in the field of forensic science, especially in forensic pathology, it is still in the stage of exploration. This paper reviews the research techniques and the use of proteomics in forensic pathology in domestic and foreign scholars, in order to provide new ideas for the research and application of forensic pathology.

Actuaries utilize demographic features such as mortality and longevity rates for pricing, valuation, and reserving life insurance and pension contracts. Capturing accurate mortality estimates requires factual mortality assumptions in mortality models. However, the dynamic and uncertain nature of mortality improvements and deteriorations necessitates better approaches in tracking mortality changes, for instance, using the causes of deaths features. This paper aims to determine temporal homogeneous clusters using unsupervised learning, a clustering approach to group causes of death based on (dis)similarity measures to set representative clusters in detection and monitoring death trends. The causes of death dataset were derived from the World Health Organization, Global Health Estimates for males and females, from 2000 to 2019, for Kenya. A hierarchical agglomerative clustering technique was implemented with modified Dynamic Time Warping distance criteria. Between 6 and 14 clusters were optimally achieved for both males and females. Using visualisations, principal clusters were detected. Over time, the causes of death trends of these clusters have demonstrated a correlated association with mortality and longevity rates, rationalizing why insurance and pension offices may include this approach as a preliminary step to undertake mortality and longevity modelling.

This paper provides an examination into some of the most enduring debates regarding tuberculosis mortality during the nineteenth century: those related to gender, geographic and temporal variations. We use populations reconstructed from individual census and civil register data for the period 1861 to 1901, comparing a growing urban area with a declining rural area, both with around 20,000 inhabitants in 1861. Our analysis shows that among young adults tuberculosis was linked to excess female mortality in the urban area and excess male mortality in the rural area. We demonstrate that in the town textile workers of both genders had particularly high mortality from tuberculosis, and that the only reason for higher overall female mortality was the predominance of young women in the textile labour force. We show that the age and gender-specific pattern of mortality in the rural area is consistent with higher male than female out-migration together with return migration of those who had contracted the disease elsewhere and needed care during their lengthy illness. We argue that the observed patterns are difficult to reconcile with the ‘bargaining-nutrition’ account of gendered patterns in tuberculosis mortality, and that they provide little support for nutrition as a key influence on the disease. However, our findings do reinforce Andrew Hinde’s recent argument that geographical patterns in sex-specific tuberculosis mortality rates were largely determined by migration patterns, and we discuss the implications of this for our understanding of the decline of the disease over the late nineteenth century.

Since December 2019, a new form of coronavirus, SARS-CoV-2, has spread from China to the whole word, raising concerns regarding Coronavirus Disease 2019 (COVID-19) endangering public health and life. Over 1.5 million deaths related with COVID-19 have been recorded worldwide, with wide variations among countries affected by the pandemic and continuously growing numbers. The aim of this paper was to provide an overview of the literature cases of deaths involving COVID-19 and to evaluate the application of the COVID-19 Significance Score (CSS) in the classification of SARS CoV-2-related fatalities, comparing it with the Hamburg rating scale. The results obtained allowed us to highlight that CSS used after a complete accurate post-mortem examination, coupled to the retrieval of in vivo data, post-mortem radiology, histology and toxicology, as well as to additional required analyses (e.g., electronic microscopy) is a useful and concise tool in the assessment of the cause of death and the role played by this virus. A shared use of this scale might hopefully lower the inhomogeneities in forensic evaluation of SARS CoV-2-related fatalities.

Marine debris is a growing threat to hundreds of marine animal species. To understand the consequences of marine debris to wildlife populations, studies must go beyond reporting the incidence of wildlife and debris interactions and aim to quantify the harm resulting from these interactions. Tubenosed seabirds are globally threatened, with a near universal risk of debris ingestion and an unquantified risk of mortality due to eating plastics. In this paper, we explore the mortality risk narrative due to the acute effects of debris ingestion, and quantify behavioural and ecological factors including age, diet and foraging method. We examined ingested debris loads, types and mortality of 972 adult and immature seabirds across 17 albatross, shearwater and prion species in a global seabird biodiversity hotspot. Though age and foraging method interact to influence the incidence and number of items ingested, age and diet were the most important factors influencing mortality. Mortality is influenced by debris load and type of debris ingested and there is selectivity for items that visually resemble a seabird’s prey. Immature birds that forage on cephalopods are more likely to ingest and die from eating debris than are adults. Conversely, the risk of death to seabirds that forage on crustaceans is linked to the number of plastic items ingested and is higher in adults. Debris ingestion is an under-recognised cause of tubenose mortality and is likely negatively affecting rare and threatened species.

This paper provides an examination into some of the most enduring debates regarding tuberculosis mortality during the nineteenth century: those related to gender, geographic and temporal variations. We use populations reconstructed from individual census and civil register data for the period 1861 to 1901, comparing a growing urban area with a declining rural area, both with around 20,000 inhabitants in 1861. Our analysis shows that among young adults tuberculosis was linked to excess female mortality in the urban area and excess male mortality in the rural area. We demonstrate that in the town textile workers of both genders had particularly high mortality from tuberculosis, and that the only reason for higher overall female mortality was the predominance of young women in the textile labour force. We show that the age and gender-specific pattern of mortality in the rural area is consistent with higher male than female out-migration together with return migration of those who had contracted the disease elsewhere and needed care during their lengthy illness. We argue that the observed patterns are difficult to reconcile with the ‘bargaining-nutrition’ account of gendered patterns in tuberculosis mortality, and that they provide little support for nutrition as a key influence on the disease. However, our findings do reinforce Andrew Hinde’s recent argument that geographical patterns in sex-specific tuberculosis mortality rates were largely determined by migration patterns, and we discuss the implications of this for our understanding of the decline of the disease over the late nineteenth century.

This paper provides an examination into some of the most enduring debates regarding tuberculosis mortality during the nineteenth century: those related to gender, geographic and temporal variations. We use populations reconstructed from individual census and civil register data for the period 1861 to 1901, comparing a growing urban area with a declining rural area, both with around 20,000 inhabitants in 1861. Our analysis shows that among young adults tuberculosis was linked to excess female mortality in the urban area and excess male mortality in the rural area. We demonstrate that in the town textile workers of both genders had particularly high mortality from tuberculosis, and that the only reason for higher overall female mortality was the predominance of young women in the textile labour force. We show that the age and gender-specific pattern of mortality in the rural area is consistent with higher male than female out-migration together with return migration of those who had contracted the disease elsewhere and needed care during their lengthy illness. We argue that the observed patterns are difficult to reconcile with the ‘bargaining-nutrition’ account of gendered patterns in tuberculosis mortality, and that they provide little support for nutrition as a key influence on the disease. However, our findings do reinforce Andrew Hinde’s recent argument that geographical patterns in sex-specific tuberculosis mortality rates were largely determined by migration patterns, and we discuss the implications of this for our understanding of the decline of the disease over the late nineteenth century.

This paper provides an examination into some of the most enduring debates regarding tuberculosis mortality during the nineteenth century: those related to gender, geographic and temporal variations. We use populations reconstructed from individual census and civil register data for the period 1861 to 1901, comparing a growing urban area with a declining rural area, both with around 20,000 inhabitants in 1861. Our analysis shows that among young adults tuberculosis was linked to excess female mortality in the urban area and excess male mortality in the rural area. We demonstrate that in the town textile workers of both genders had particularly high mortality from tuberculosis, and that the only reason for higher overall female mortality was the predominance of young women in the textile labour force. We show that the age and gender-specific pattern of mortality in the rural area is consistent with higher male than female out-migration together with return migration of those who had contracted the disease elsewhere and needed care during their lengthy illness. We argue that the observed patterns are difficult to reconcile with the ‘bargaining-nutrition’ account of gendered patterns in tuberculosis mortality, and that they provide little support for nutrition as a key influence on the disease. However, our findings do reinforce Andrew Hinde’s recent argument that geographical patterns in sex-specific tuberculosis mortality rates were largely determined by migration patterns, and we discuss the implications of this for our understanding of the decline of the disease over the late nineteenth century.

This paper provides an examination into some of the most enduring debates regarding tuberculosis mortality during the nineteenth century: those related to gender, geographic and temporal variations. We use populations reconstructed from individual census and civil register data for the period 1861 to 1901, comparing a growing urban area with a declining rural area, both with around 20,000 inhabitants in 1861. Our analysis shows that among young adults tuberculosis was linked to excess female mortality in the urban area and excess male mortality in the rural area. We demonstrate that in the town textile workers of both genders had particularly high mortality from tuberculosis, and that the only reason for higher overall female mortality was the predominance of young women in the textile labour force. We show that the age and gender-specific pattern of mortality in the rural area is consistent with higher male than female out-migration together with return migration of those who had contracted the disease elsewhere and needed care during their lengthy illness. We argue that the observed patterns are difficult to reconcile with the ‘bargaining-nutrition’ account of gendered patterns in tuberculosis mortality, and that they provide little support for nutrition as a key influence on the disease. However, our findings do reinforce Andrew Hinde’s recent argument that geographical patterns in sex-specific tuberculosis mortality rates were largely determined by migration patterns, and we discuss the implications of this for our understanding of the decline of the disease over the late nineteenth century.

The subject of the work included 41 cases of death in which amphetamine was involved as the direct or indirect cause. Identification and determination of xenobiotics in blood samples collected from post-mortem cases were performed by high-performance liquid chromatography coupled with tandem mass spectrometry with electrospray ionisation (HPLC-ESI-MS-MS). Only for two cases was the cause of death amphetamine poisoning. In most of the investigated cases the death was caused by poisoning due to complex amphetamine and other psychoactive substances (e.g. opiates, benzodiazepines, cocaine). In other cases, multi-organ damage (fall from a height, traffic accident), a puncture wound and wound incised, drowning, or asphyxiation by hanging were reported. It can be explained as risky, murderous, or suicidal actions of people who were under the influence of amphetamines. The presented paper focuses on the interpretation of amphetamine concentration in blood samples from the perspective of direct or indirect cause of death.

Background: A systematic review of child Death (CDR) was required to improve the quality of neonatal health care to avoid more deaths in that particular group especially. So the present research was carried out to study the reasons behind neonatal mortality in the present tertiary care referral centre. Material and Methods: A cross- sectional study by reviewing case paper of deceased children between 1-5 yrs died in a tertiary care hospital in Surat. Results: Total live births were 7677, 197 died within 28 days, i.e neonatal mortality rate is 25.66 and 223 died within a year i.e. infant mortality rate is 29.04. Among the ELBW babies 68.1% died, in VLBW babies 29.5% died, in LBW babies 10.96% died and in normal weight baby 7.2% died. Out of total NICU admission 43.5 % were preterm, out of which 49.36% were extremely premature while 50.63% were premature. Out of total 197 neonatal deaths, sepsis was responsible in 69.54% cases followed by extreme prematurity or prematurity (52.1%). Conclusions: Immediate cause of death was sepsis, HMD, MAS and birth asphyxia. Underlying cause was extreme prematurity, prematurity, sepsis and birth asphyxia. Contributory factors were ELBW, VLBW and LBW. Maturity and birth weight are two most important factors which needs emphasis for prevention of neonatal deaths.

Background: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low- and lower-middle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death. Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance. Conclusions: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems.

Background: Bangladesh has achieved remarkable gains in health indicators during the last four decades despite low levels of economic development. However, the persistence of inequities remains disturbing. This success was also accompanied by health and demographic transitions, which in turn brings new challenges for a nation that has yet to come to terms with pre-transition health challenges. It is therefore important to understand the causes of death and their relationship with socioeconomic status (SES). Objective: The paper aims to assess the causes of death by SES based on surveillance data from a rural area of Bangladesh, in order to understand the situation and inform policy makers and programme leaders. Design: We analysed population-based mortality data collected from the Chakaria Health and Demographic Surveillance System in Bangladesh. The causes of death were determined by using a Bayesian-based programme for interpreting verbal autopsy findings (InterVA-4). The data included 1,391 deaths in 217,167 person-years of observation between 2010 and 2012. The wealth index constructed using household assets was used to assess the SES, and disease burdens were compared among the wealth quintiles. Results: Analysing cause of death (CoD) revealed that non-communicable diseases (NCDs) were the leading causes of deaths (37%), followed by communicable diseases (CDs) (22%), perinatal and neonatal conditions (11%), and injury and accidents (6%); the cause of remaining 24% of deaths could not be determined. Age-specific mortality showed premature birth, respiratory infections, and drowning were the dominant causes of death for childhood mortality (0–14 years), which was inversely associated with SES (p

Background: Medical Insurance Siglo XXI (MISXXI) in Mexico provides funds for the medical and preventive care of children from households lacking any health insurance, thus seeking to reduce impoverishing due to health problems. This paper analyzes mortality of children

Este artículo examina la incertidumbre presente en una de las mediciones más usada para análisis y toma de decisiones en salud pública. Adapta la medida de entropía de Shannon-Wiener para expresar la incertidumbre contenida en el conteo de las causas de muertes en las estadísticas vitales oficiales de Chile. A partir de los hallazgos, discute los requerimientos metrológicos en salud pública, tan importantes como las mediciones mismas. Considera y argumenta la existencia de una incertidumbre adicional, asociada con las propiedades performativas de las estadísticas. Tanto por la forma de estructurar los datos a la manera de una cierta sintaxis de lo real, como por las exclusiones de aquello que queda más allá de la modelación cuantitativa usada en cada caso. Mediante una aproximación a la herencia del pensamiento pragmático, y usando herramientas conceptuales de la sociología de la traducción, destaca que la incertidumbre puede contribuir en salud pública a un debate acerca de la vinculación entre técnica, democracia y la formación de un público.This paper addresses the issue of uncertainty in the measurements used in public health analysis and decision-making. The Shannon-Wiener entropy measure was adapted to express the uncertainty contained in counting causes of death in official vital statistics from Chile. Based on the findings, the authors conclude that metrological requirements in public health are as important as the measurements themselves. The study also considers and argues for the existence of uncertainty associated with the statistics' performative properties, both by the way the data are structured as a sort of syntax of reality and by exclusion of what remains beyond the quantitative modeling used in each case. Following the legacy of pragmatic thinking and using conceptual tools from the sociology of translation, the authors emphasize that by taking uncertainty into account, public health can contribute to a discussion on the relationship between technology, democracy, and formation of a participatory public.

OBJECTIVE: This paper assesses the quality of the underlying cause of death (COD) statistics in Hermosillo, Mexico in a random sample of 300 in-hospital adult deaths. MATERIAL AND METHODS: A "gold standard" COD, determined by a systematic review of hospital medical charts, was compared to the COD reported by the vital registry system. RESULTS: Overall agreement between the reviewer and original COD at the ICD-10 chapter block was 69.2%, with a weighted kappa of 0.62. Agreement varied greatly by ICD-10 chapter. Mutual misclassification among common co-morbidities,such as diabetes mellitus and circulatory disease, minimized the net change in the mortality fraction assigned to each ICD-10 chapter after physician review. CONCLUSIONS: The ICD-10 chapter level underlying COD codes can be used to estimate disease burden in the population. Caution is recommended for use of vital registry statistics in Hermosillo for individual level or disease-specific analyses.OBJETIVO: Examinar la validez de la causa básica de muerte (CBM) de certificados de defunción de un sistema digital de vigilancia epidemiológica en Hermosillo, México. MATERIAL Y MÉTODOS: Se comparó la CBM originalmente codificada en una muestra aleatoria de 300 certificados de defunción de muertes adultas ocurridas en al año 2005, con la CBM determinada por una revisión de expedientes médicos. RESULTADOS: Se identificó una concordancia global de 69.2% entre la CBM original y la determinada por la revisión, con un coeficiente de kappa de 0.62. La concordancia varió,con errores de codificación en padecimientos como diabetes mellitus, enfermedades circulatorias y respiratorias y neoplasias. El efecto de esos errores fue compensado por una mutua asignación equivocada en el proceso de codificación de la CBM empleado por el sistema. CONCLUSIONES: Las estadísticas generadas por el sistema examinado pueden usarse con cautela para estimar la carga poblacional de mortalidad en Hermosillo, México.

Cause-of-death data derived from verbal autopsy (VA) are increasingly used for health planning, priority setting, monitoring and evaluation in countries with incomplete or no vital registration systems. In some regions of the world it is the only method available to obtain estimates on the distribution of causes of death. Currently, the VA method is routinely used at over 35 sites, mainly in Africa and Asia. In this paper, we present an overview of the VA process and the results of a review of VA tools and operating procedures used at demographic surveillance sites and sample vital registration systems. We asked for information from 36 field sites about field-operating procedures and reviewed 18 verbal autopsy questionnaires and 10 cause-of-death lists used in 13 countries. The format and content of VA questionnaires, field-operating procedures, cause-of-death lists and the procedures to derive causes of death from VA process varied substantially among sites. We discuss the consequences of using varied methods and conclude that the VA tools and procedures must be standardized and reliable in order to make accurate national and international comparisons of VA data. We also highlight further steps needed in the development of a standard VA process.

OBJETIVO: Estudar a mortalidade relacionada à tuberculose no Estado de São Paulo segundo causas múltiplas de morte, e suas inter-relações com outras causas básicas. MÉTODOS: Foram estudados os óbitos ocorridos e no Estado de São Paulo, em 1998, tendo como causa a tuberculose. Os dados foram obtidos na Fundação Sistema Estadual de Análise de Dados (SEADE). As causas de morte pelas formas clínicas da tuberculose foram codificadas no agrupamento A15-A19 e suas seqüelas na categoria B90, segundo as disposições da Décima Revisão da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde. As causas associadas de morte foram processadas pelo Tabulador de Causas Múltiplas (TCM). Para análise estatística, foram usados o teste de variância, o teste t de Student e qui-quadrado. RESULTADOS: A tuberculose foi considerada a causa básica em 1.644 óbitos, correspondendo ao coeficiente de mortalidade de 4,6/100.000 habitantes. As principais causas associadas forami a insuficiência respiratória (46,9%), pneumonias (16,5%), outros sintomas e sinais especificados relativos aos aparelhos circulatório e respiratório (13,9%), caquexia (12,9%), doenças do sistema circulatório (10,3%), afecções devidas ao uso do álcool (8,4%), septicemias (7,2%) e desnutrição (7,1%). Como causa associada, a tuberculose ocorreu em outras 1.388 mortes. O coeficiente de mortalidade, incluindo a tuberculose como causa básica ou associada, foi de 8,9/100.000 habitantes, praticamente o dobro do valor do coeficiente clássico. As mortes em que a tuberculose foi mencionada como causa associada teve como principal causa básica a Aids (65,3%). As formas clínicas de tuberculose do sistema nervoso e miliar foram mais freqüentes como causas associadas de Aids que nos óbitos devido a outras causas básicas de morte (pOBJECTIVES: The goal of this paper is to investigate mortality related to tuberculosis in the state of São Paulo, southeastern Brazil, according to multiple causes of death and their interrelation with other underlying causes. METHODS: The study investigated deaths related to tuberculosis that occurred in the state of São Paulo in 1998. Data were obtained from the Fundação Sistema Estadual de Análise de Dados (State System for Data Analysis Foundation - SEADE) database. Causes of death by clinical forms of TB were coded in block A15-A19, and by its sequelae in category B90, according to the guidelines proposed by the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems. Tabulador de Causas Múltiplas (Multiple Cause Tabulator - TCM) software was used for processing associated causes of death. Statistical analysis included analysis of variance, Student's t -distribution, and chi-squared tests. RESULTS: TB was the underlying cause of 1,644 deaths, a 4.6/100,000 population mortality rate. Main associated causes were respiratory failure (46,9%), pneumonias (16.5%), other specified symptoms and signs involving circulatory and respiratory systems (13.9%), cachexia (12.9%), diseases of the circulatory system (10.3%), conditions due to alcohol use (8.4%), septicemias (7.2%) and malnutrition (7.1%). Tuberculosis occurred as an associated cause in another 1,388 deaths. The mortality rate including TB as a both underlying and associated cause was 8.9/100,000 population, practically twice the classical rate. Deaths whose associated cause was reported as being TB had as underlying causes: AIDS (65.3%), diseases of the circulatory system (8.9%), neoplasms (7.5%), and diseases of the digestive system (4.8%). Clinical forms of nervous system and miliary TB were more frequent as a cause associated with AIDS than with other underlying causes (p

Background: While the health crisis in the former USSR has been well-documented in the case of Russia and other northern former Soviet republics, little is known about countries located in the southern tier of the region, i.e., the Caucasus and Central Asia. Objective: This paper presents new mortality information from two Caucasian countries, Georgia and Armenia. Results are compared with information from two relevant countries previously examined in the literature, Kyrgyzstan and Russia. Methods: Using official statistics (with adjustments when necessary), we compare adult mortality patterns in the four countries since 1979, for all causes and by cause for the recent period. For Kyrgyzstan results are presented by ethnicity, as its mortality levels have been impacted by its large Slavic population. Results: Adult mortality patterns in Armenia and Georgia have been more favorable than in Russia. This appears to be due to a large extent to lower mortality from alcohol-related causes. Mortality patterns in these Caucasian republics resemble those observed in Kyrgyzstan, especially when considering the native portion of the population. Conclusions: As far as mortality is concerned, Armenia and Georgia have weathered the collapse of the Soviet Union better than Russia. These results document a distinct southern tier pattern of adult mortality in the former Soviet Union. Contribution: This article enriches our understanding of the health crisis in the former Soviet Union by bringing new information from two lesser-known countries and further documenting the scale of heterogeneity in mortality experiences across this vast region.

Background: The decline of child mortality during the late 19th century is one of the most significant demographic changes in human history. However, there is evidence suggesting that the substantial reductions in mortality during the era did little to reduce mortality inequality between socioeconomic groups. Objective: The aim of this study is to examine the development of socioeconomic inequalities in cause-specific infant and child mortality during Stockholm's demographic transition. Methods: Using an individual-level longitudinal population register for Stockholm, Sweden, between 1878 and 1926, I estimate Cox proportional hazards models to study how inequality in cause-specific hazards of dying from six categories of causes varied over time. The categories included are 1) airborne and 2) food and waterborne infectious diseases, 3) other infectious diseases, 4) noninfectious diseases and accidents, 5) perinatal causes, and 6) unspecified causes. Results: The results show that class differentials in nearly all causes of death converged during the demographic transition. The only exception was the airborne infectious disease category, for which the gap between white-collar and unskilled blue-collar workers widened over time. Conclusions: The results demonstrate that, even in a context of falling mortality and a changing epidemiological environment, higher socioeconomic groups were able to maintain a health advantage for their children by reducing their risks of dying from airborne disease to a greater extent than other groups. Potential explanations for these patterns are suggested, as well as suggestions for future research. Contribution: This is the first paper to use individual-level cause-of-death data to study the long-term trends in inequality of cause-specific child mortality during the demographic transition.

The present paper examines, describes and documents country-specific trends in under-five mortality rates (i.e., mortality among children under five years of age) in the 1990s. Our analysis updates previous studies by UNICEF, the World Bank and the United Nations. It identifies countries and WHO regions where sustained improvement has occurred and those where setbacks are evident. A consistent series of estimates of under-five mortality rate is provided and an indication is given of historical trends during the period 1950-2000 for both developed and developing countries. It is estimated that 10.5 million children aged 0-4 years died in 1999, about 2.2 million or 17.5% fewer than a decade earlier. On average about 15% of newborn children in Africa are expected to die before reaching their fifth birthday. The corresponding figures for many other parts of the developing world are in the range 3-8% and that for Europe is under 2%. During the 1990s the decline in child mortality decelerated in all the WHO regions except the Western Pacific but there is no widespread evidence of rising child mortality rates. At the country level there are exceptions in southern Africa where the prevalence of HIV is extremely high and in Asia where a few countries are beset by economic difficulties. The slowdown in the rate of decline is of particular concern in Africa and South-East Asia because it is occurring at relatively high levels of mortality, and in countries experiencing severe economic dislocation. As the HIV/AIDS epidemic continues in Africa, particularly southern Africa, and in parts of Asia, further reductions in child mortality become increasingly unlikely until substantial progress in controlling the spread of HIV is achieved.

Hace más de 12 años publicamos un trabajo acerca de cómo confeccionar correctamente el certificado médico de defunción del adulto, y con ello respondimos a una orientación de la Dirección Nacional de Salud Pública. Luego de aquella publicación, se han hecho otras, pero aún persisten deficiencias en este procedimiento médico legal, lo que por sí solo justifica una nueva incursión. Además, ha surgido un nuevo modelo con algunos elementos que debemos aclarar y tener en cuenta, por lo que decidimos realizar una revisión de esta temática y brindar un material que pueda ayudar fundamentalmente a los médicos de asistencia y alumnos de 5to año de la carrera de Medicina a confeccionar correctamente el nuevo certificado médico de defunción del adulto. Se hará especial hincapié en tres aspectos fundamentales: lo nuevo de este certificado de defunción, la distinción de las causas de muerte, así como su secuencia, ya que otros temas pueden ser profundizados por la bibliografía acotada en el texto.More than 12 years ago, we published a paper on how to issue the adult's death certificate correctly, giving an answer this way to a guidline of the National Public Health Division. There have been other publications, but there are still deficiencies in this legal medical procedure, which justifies by itself a new approach. As it has appeared a new form with some elements that should be cleared and taken into consideration, we decided to make a review of this topic and to provide a new material to help mainly assistance physicians and 5th year medical students to fill out the new adult's death certificate adequately. Special emphasis is made on 3 fundamental aspects: the new of this death certificate, the distinction of death causes and its sequence, since other topics may be dealt with by referring to the bibliography annotated in the text.

Abstract Background The injury mortality burden of Guinea has been rarely addressed. The paper aimed to report patterns of injury mortality burden in Guinea. Methods We retrieved the mortality data from the Guinean Annual Health Statistics Report 2007. The information about underlying cause of deaths was collected based on Guinean hospital discharge data, Hospital Mortuary and City Council Mortuary data. The causes of death are coded in the 9th International Classification of Diseases (ICD-9). Multivariate Poisson regression was used to test the impacts of sex and age on mortality rates. The statistical analyses were performed using Statatm 10.0. Results In 2007, 7066 persons were reported dying of injuries in Guinea (mortality: 72.8 per 100,000 population). Transportation, fire/burn, falls, homicide and drowning were the five leading causes of fatal injuries for the whole population, accounting for 37%, 22%, 12%, 10% and 6% of total deaths, respectively. In general, age-specific injury causes displayed similar patterns of the whole population except that poisoning replaced falls as a leading cause among children under five years old. Males were at 30-50% more risk of dying from six commonest causes than females and old age groups had higher injury mortality rates than younger age groups. Conclusion Transportation, fire/burn, falls, homicide, and drowning accounted for the majority of total injury mortality burden in Guinea. Males and old adults were high-risk population of fatal injuries and should be targeted by injury prevention. Lots of work is needed to improve weak capacities for injury control in order to reduce the injury mortality burden.

Abstract Background Relating Information on causes of deaths to implementation of health interventions provides vital information for program planning and evaluation. This paper from Ballabgarh Health and Demographic Surveillance System (HDSS) site in north India looks at temporal trends and gender differentials in the causes of death among under-five children. Methods Data on causes of death for 1972-74, 1982-84, 1992-94, 2002-04 were taken from existing HDSS publications and database. Physicians’ assigned causes of death were based on narratives by lay health worker till 1994 and later by verbal autopsy. Cause Specific Mortality Fractions (CSMF) and Cause Specific Mortality Rates (CSMR) per 1000 live births were calculated for neonatal ( Results The CSMF of prematurity and sepsis was 32% and 17.6% during neonatal period in 2002-04. The share of infections in all childhood deaths decreased from 55.2% in 1972-74 to 43.6% in 2002-04. All major causes of mortality (malnutrition, diarrhea and acute lower respiratory infection) except injuries showed a steep decline among children and seem to have plateued in last decade. Most of disease specific public health interventions were launched in mid eighties. . Girls reported significantly higher mortality rates for prematurity (RR 1.52; 95% CI 1.01-2.29); diarrhea (2.29; 1.59 – 3.29), and malnutrition (3.37; 2.05 – 5.53). Conclusions The findings of the study point out to the need to move away from disease-specific to a comprehensive approach and to address gender inequity in child survival through socio-behavioural approaches.

Abstract Background Mortality statistics are essential for population health assessment. Despite limitations in data availability, Pacific Island Countries are considered to be in epidemiological transition, with non-communicable diseases increasingly contributing to premature adult mortality. To address rapidly changing health profiles, countries would require mortality statistics from routine death registration given their relatively small population sizes. Methods This paper uses a standard analytical framework to examine death registration systems in Fiji, Kiribati, Nauru, Palau, Solomon Islands, Tonga and Vanuatu. Results In all countries, legislation on death registration exists but does not necessarily reflect current practices. Health departments carry the bulk of responsibility for civil registration functions. Medical cause-of-death certificates are completed for at least hospital deaths in all countries. Overall, significantly more information is available than perceived or used. Use is primarily limited by poor understanding, lack of coordination, limited analytical skills, and insufficient technical resources. Conclusion Across the region, both registration and statistics systems need strengthening to improve the availability, completeness, and quality of data. Close interaction between health staff and local communities provides a good foundation for further improvements in death reporting. System strengthening activities must include a focus on clear assignment of responsibility, provision of appropriate authority to perform assigned tasks, and fostering ownership of processes and data to ensure sustained improvements. These human elements need to be embedded in a culture of data sharing and use. Lessons from this multi-country exercise would be applicable in other regions afflicted with similar issues of availability and quality of vital statistics.

In this paper, we use the multiple cause-of-death approach to compare the mortality profiles of France and Italy in 2003. Our analysis leads to a substantial re-evaluation of the role played by certain conditions in the process leading to death. Regarding the associations of causes, we distinguish three patterns that are common to both countries. The numerous similarities that emerge from the comparison of the two countries are a clear indication that, contrary to what is generally thought, misreporting by the certifying physicians generally do not distort the observation.

A 'population observatory' is a study in which a whole population of a defined geographical area is monitored over a long period (several years or decades), and information on the events that happen (births, deaths, marriages, migration) is collected on a regular basis. This paper presents the collection method used in population observatories, the type of results that they provide, and how they are useful for the study of mortality in the nations of the South. In the first part, the different observatories in the developing countries are reviewed, and certain specific aspects of their methodology are studied in detail. In the second part two examples are presented - the observatories of Bandafassi and Mlomp, in Senegal.

This paper performs a systematic analysis of all currently available Russian data on mortality by region, census year (1970, 1979, 1989, and 1994) and cause of death. It investigates what links may be found between these geographical variations in cause-specific mortality, the negative general trends observed since 1965, and the wide fluctuations of the last two decades. For that, four two-year periods of observation were selected where it was possible to calculate fairly reliable mortality indicators by geographic units using census data for 1970, 1979, 1989, and micro-census data for 1994, and used a clustering model. Behind the complexity of the studied universe, three main conclusions appeared. Firstly, in European Russia, there is a stark contrast between south-west and north-east, both in terms of total mortality and of cause-of-death patterns. Secondly, analysis of overall cause-of-death patterns for all periods combined clearly confirms that contrast at the whole country level by the prolongation of the southern part of European Russia through the continuation of the black soil ("chernoziom") belt along the Kazakhstan border, while the rest of Siberia presents a radically different picture to European Russia. Thirdly, while it is difficult to infer any permanent geographical pattern of mortality from that very fluctuating piece of history, 1988-89 appears to be a base period for at least the entire period from 1969-1994.

Abdel Omran's 1971 theory of "Epidemiologic Transition" was the first attempt to account for the extraordinary advances in health care made in industrialized countries since the 18th century. In the framework of the Demographic Transition, it implied a general convergence of life expectancies toward a limit imposed by the new epidemiological features of modern societies. However, important failures, occurred in the past decades (mainly the health crisis in Eastern Europe and AIDS in Africa), seem to have stopped that process of convergence. In fact such failures do not really contradict the theory. The latter is much more ruined by the unexpected dramatic improvement in the field of cardiovascular disease experienced since the seventies, which results in a new step of a more general process. On the basis of the broader concept of "Health Transition" initiated by Julio Frenk et al., the present paper tries to rethink the full process in term of divergence/convergence sequences inferred by successive major changes in health technologies and strategies.