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A scandal of invisibility: making everyone count by counting everyone

Most people in Africa and Asia are born and die without leaving a trace in any legal record or statistic, a situation which has arisen due to the stagnation of civil registration systems in many poor countries.

These are the conclusions of Dr Philip Setel, MEASURE Evaluation, Carolina Population Centre, University of North Carolina, NC, USA, and colleagues, authors of this first paper in the Who Counts? Series in The Lancet.

Including debt relief, official development assistance globally reached $US 80 billion in 2004 – yet the authors say that absence of vital statistics means that there is “little authoritative evidence that these funds have their desired effects on either mortality or poverty reduction.”

Civil registration, including the medical certification of deaths and causes of death, together with the statistics they generate can benefit both individuals and societies. Legal documents that prove identity and citizenship not only provide access to state benefits or entitlements and provide the necessary documentary basis for establishing property ownership and inheritance, but also protect against exploitation or protracted hardship in times of emergency. The authors say: “The persistent failure to establish, support, and sustain civil registration systems over the past 30 years, and to ensure that causes of death are accurately known in the world’s poorest countries is a scandal of invisibility, for which affordable remedies exist and need to be implemented.”

The paper cites numerous cases that show how such data are central to policy formation. For developed countries as a whole, information on increasing rates of road traffic fatalities up to the 1970s led to speed limits, seatbelt laws, and laws on alcohol use and driving. The remarkable reduction in traffic mortality trends closely followed the introduction of these measures and has been seen in many studies. In India, birth monitoring data has allowed population progress to be monitored – and has also shed light on some objectionable ramifications of new medical technologies – such as revealing the extent to which female foetuses have been selectively aborted. Case studies of Chile (maternal and newborn health) and Tanzania (cause of death) are also analysed.

Risks of data registration are also explored. The authors say: “Unless identities are protected, this powerful instrument can be – and has been – used to do great harm to individuals and vulnerable minorities.” Examples are the used of Dutch population registers by the Nazi regime to locate and exterminate Jewish families, and the role of identity cards in the Rwanda Genocide.

The authors say that whereas the increasing awareness of the AIDS pandemic worldwide shows that visibility demands accountability, there exists no global imperative to make unregistered people more visible, and “far from advancing into this century, the inadequate state of civil registration in developing countries remains mainly as it was three decades ago.”

They conclude: “Overcoming decades of stagnation will need countries to make a principled long-term commitment to comprehensive civil registration, and to make pragmatic use of complementary or alternative registration systems and sources of data for vital events and cause of death in the short term and medium term.

“The continued cost of ignorance borne by countries without civil registration far outweighs the affordable necessity of action.”

Tony Kirby | alfa
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