Conversations with the Director: Sam Notzon, PhD

February 8, 2013

Photo by Edward L. Johnson

Vital Statistics Are Vital in Public Health
A Conversation with Sam Notzon, PhD, National Center for Health Statistics

CDC Director Tom Frieden, MD, MPH, spoke with health statistician Sam Notzon, PhD, about the important role of registration and vital statistics in public health around the world. Notzon defined a well-functioning registration and vital statistics system as having six unique characteristics—easy to remember, he told Frieden, because they all begin with the letter “c.”

“There are all sorts of things that the system can do—that surveys or other data sources can’t:

• it’s continuous (it happens year after year);
• it’s comparable (so you get trends year after year);
• it’s complete (so you get small area data);
• it’s contemporaneous (so you get data shortly after the event has happened, rather than retrospective surveys);
• it gives you cause of death (which is a huge effort, if done right); and
• if you look at the health data as the statistical byproduct of an administrative data system, then it’s cheap.” (which is a plus in these tight budget times!)

Their conversation touched on the personal and professional as they swapped stories and exchanged ideas.

Notzon has worked at the National Center for Health Statistics (NCHS), part of the Office of Surveillance, Epidemiology and Laboratory Services (OSELS), since 1976. Years of experience have taught Notzon what can hinder an effective registration and vital statistics program. Lack of cooperation is a major stumbling block, because many countries lack a single organization responsible for vital statistics. Typically, three ministries are involved—Interior, Health, and Department of Statistics—and getting them to work together is often unwieldy.

Distance and money are also challenges. “You can put a lot of money into a system and make it work well,” Notzon explained, “but if the country can’t afford the system when your project ends, it will go away. Sad to say, but that’s what happens. So that’s the real challenge—finding imaginative solutions that are cheap enough for the country to maintain.”

Frieden and Notzon discussed changes in global technology that allow more accurate reporting of data. For instance, in pilot programs proposed for Kenya and Malawi, CDC and other partners will buy air time so that community health workers can use their cell phones to gather updated information about births and deaths. By personally visiting households and collecting data, community health workers serve as the “eyes and ears” of vital statistics and help transform a passive registration system into a more active one. (Now that’s creative, another “c” word!)

Notzon mentioned an international collaboration that has worked for more than 15 years to develop a system of automated applications for mortality statistics. The system, named IRIS, is easy to adapt for use in numerous languages and links physician diagnoses to the ICD codes. It is more consistent than manual coding and far superior in the accurate selection of the underlying cause of death.

Frieden steered the conversation to technical packages. “You may have heard me talk about technical packages. I’m a big fan of ‘What are the essential components you need to do to get the outcomes you want to get?’…So, what is the technical package for vital registration in low- and middle-income countries? What does it consist of?”

Notzon was quick to identify several needed components, such as active surveillance, (including community health workers); training physicians to report causes of death for deaths that occur in the hospital; good communication between field staff, local registration offices, and central offices; updated technology at the central office; analytics (managing the databases); and money.

Frieden was very interested in examples where vital registration data had resulted in a changed health policy. Notzon pointed out South Africa and Jordan, adding that when he visits a country he always informs the CDC country director that civil registration and vital statistics training materials are available as a part of their FETP (Field Epidemiology Training Program) curriculum.

The two agreed that accurate birth and death certificates are the fundamental drivers of a sound, consistent registration and vital statistics system. And when it comes to vital records, consistency is an extremely important “c” word.

This Inside Story by Faye McDonald Smith.