Importance of Standardization of Mortality Rates Essay

Standardization is an essential tool for the evaluation of public health status through comparing morbidity and mortality of two or more populations. It is beneficial for comparing mortality rates concerning the structure of both communities. While researchers can compare crude rates, they may be misleading due to being uninformative about the characteristics of the group under study (“Standardization,” n.d.).

Age and sex are the two most common variables that call for standardized rates. For instance, if Population A has a higher crude mortality rate from prostate cancer than Population B, one can conclude that Population A is more exposed to prostate cancer. However, this can be untrue, as Population A may consist mainly of males, while Population B could include mostly females. Therefore, obtaining standardized rates is crucial for receiving adequate epidemiology data.

There two primary methods of standardization that are applied under different circumstances depending on the set of available data. The direct method is useful for acquiring highly-precise epidemiological data for large groups of people when the rates are relatively stable (Martcheva, 2015). The approach can be used only when the characteristic-specific rates “for all populations being studied are available and that a standard population is defined” (“Standardization,” n.d., para. 27).

The indirect method is appropriate for small numbers, as it is less accurate due to the unavailability of characteristic-specific rates of a population (Martcheva, 2015). For instance, if the age-specific mortality rate of Population B cannot be obtained, the approach allows calculating how many deaths would be expected if it had the same age-specific mortality rates as Population A. In conclusion, both methods of standardization are essential instruments for acquiring precise epidemiological data.

Martcheva, M. (2015). An introduction to mathematical epidemiology . New York; Heidelberg: Springer.

Standardisation . (n.d.). Web.

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[An essay on birth and death reports (author's transl)]

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PIP: Demographic data is limited in developing countries and the reliability of that which is available is questionable. In this study, published data by S.I.S. on births and deaths in rural socialized areas are compared with the findings of the 1978 Turkish Fertility Survey. However, the data from the rural areas was incomplete and it was concluded that it should be used cautiously. The study also compares the dual record system survey (1975-78) results from the Yozgat Integrated MCH/FP Service Delivery Project with the data collected from reports of midwives on births and deaths during the postproject period (1979-80). This comparison was based on data from monthly activity reports of 63 health houses for more than 10 months in 1980. The data was divided into 2 parts according to where the midwife lives and works. Birth and death information from the villages covered by midwives did not accurately reflect the truth. In the villages where the midwives live, the information is more reliable. The crude birthrate was 43.3%, the crude death rate 12.7%, and the infant mortality rate was 144% in villages where the midwives lived. These findings are at acceptable levels according to the results of the dual record system survey. Findings indicated that the incompleteness of reports was mainly based on the care of administrators and midwives. The target population must be redefined in order to obtain more reliable birth and death statistics in the rural areas. This can be achieved by defining the target population as the sum of village populations where midwives live. Within these villages, midwives should remain long enough to complete their task. In addition, they should be trained in methods of data collection and should be supervised regularly. (author's modified)

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Mortality in the past: every second child died

The chances that a newborn survives childhood have increased from 50% to 96% globally. how do we know about the mortality of children in the past and what can we learn from it for our future.

A child dying is one of the most dreadful tragedies one can imagine. We all know that child deaths were more common in the past. But how common? How do we know? And what can we learn from our history?

Archeologists and historians have brought together data from many places and time periods across the world which lets us piece together a picture of our past.

Sweden is a country that has particularly good historical, demographic data. It was the first country to establish an office for population statistics: the Tabellverket, founded in 1749. Looking at the statistical records for the first three decades – the period from 1750 to 1780 – we find that 40% of children died before the age of 15. 1

During the same period about half of all children died in Bavaria (Germany), and in France the mortality rate was about 45%. At that time the average couple would have more than 5, 6, or even 7 children, which meant that most parents saw several of their children die. 2

mortality rate essay

Was this unusual? Was the death rate in Europe particularly high at that specific time?

We can look at research for other places and time periods.

Based on skeletons found in the South of modern-day Peru, paleodemographers can estimate the mortality of children who were born two millennia ago. The records suggest a similar figure: almost half of children died before the end of puberty. 3

mortality rate essay

A burial site on the Spanish island of Mallorca offers us a view on child mortality in Europe during the Iron Age. Based on the skeletons found in Mallorca researchers again found that about half of all children did not survive. 4

mortality rate essay

And the same is also true in very different regions and different periods.

mortality rate essay

Researchers also collected data about hunter-gatherer societies. The 17 different societies include paleolithic and modern-day hunter-gatherers and the mortality rate was high in all of them. On average 49% of all children died. 5 At the end of this article you can find more detail about the available evidence for the mortality rates of children in hunter-gatherer societies.

mortality rate essay

The mortality of children over the long-run

Let’s take all the historical estimates of child mortality and combine them with global data for recent decades to see what this tells us about humanity’s history. 6

What is striking about the historical research is how similar child mortality rates were across a wide range of very different historical cultures: No matter where in the world a child was born, about half of them died.

mortality rate essay

Everyone failed to make progress

Tens of billions of children died. 7 Billions of parents mourned helplessly when they saw their children dying.

Despite the relentless suffering no one was able to do much about it.

The chart speaks about societies that lived thousands of kilometers away from each other, separated by thousands of years of history, and yet they all suffered the same pain. Whether in Ancient Rome, in hunter-gatherer-societies, in the pre-Columbian Americas, in Medieval Japan or Medieval England, in the European Renaissance, or in Imperial China, every second child died.

While some societies were better off than others, the differences were small. Generation after generation was born into societies that struggled against poverty, hunger, and disease and there is no indication that any society made any substantial and sustained progress against those problems. Substantial progress against child mortality is a recent achievement everywhere.

It is not that people in the past didn’t try to make progress against early death and disease. They tried, of course. 8  Healers and doctors had a high status in societies. And people often took on great pain and costs in the hope of improving their children’s health.

The “most common procedure performed by surgeons for almost two thousand years” in Europe was bloodletting. The pain this practice caused makes clear just how desperate people were to achieve any health improvements. The fact that it not only offered no benefits, but that it was indeed harmful to the patients, makes clear just how unsuccessful humanity was for most of its history.

All were suffering as they saw their children die, yet none of them were able to do anything about it.

The key insight for me is that progress is not natural. It is hard. Even against some of the largest problems – the unrelenting death of children – thousands of generations failed to make any progress.

Are these high historical mortality rates plausible?

The historical studies of child mortality don’t provide a full picture of our ancestors' past. They are snapshots of some moments in the long history of our species. Could they mislead us to believe that mortality rates were higher than they actually were?

There is another piece of evidence to consider that suggests the mortality of children was in fact very high: birth rates were high, but population growth was close to zero.

If every couple has on average four children, the population size would double each generation. But while we know that couples had on average many more children than four, the population did not double with each generation. 9 In fact population sizes barely changed at all.

A high number of births without a rapid increase of the population can only be explained by one sad reality: a high share of children died before they could have children themselves.

If anything, the mortality rates shown in the chart above underestimate the true mortality of children. Volk and Atkinson, the two researchers who gathered most of these studies, caution that these historical mortality rates “should be viewed as conservative estimates that generally err toward underestimating actual historic rates”. 10 A first reason is that death records were often not produced for children, especially if children died soon after birth. A second reason is that child burial remains, another important source, are often incomplete “due to the more rapid decay of children's smaller physical remains and the lower frequency of elaborate infant burials”. 11

The mortality of children today

The chart above also shows the dramatic progress that was recently achieved. Most children in the world still died at extremely high rates well into the 20th century. Even as recently as 1950 – a time that some readers might well remember – one in four children died globally.

More recently, during our lifetimes, the world has achieved an entirely unprecedented improvement. In a brief episode of human history the global death rate of children declined from around 50% to 4%.

After millennia of suffering and failure, the progress against child mortality is for me one of the greatest achievements of humanity.

This is not an improvement that is only achieved by a few countries. The rate has declined in every single country in the world.

The map shows the latest available data for mortality up to the age of 15. In several countries the rate has declined to about 0.3%, a mortality rate that is more than 100-times lower than in the past. This was achieved in just a few generations. Progress can be fast.

In the richest parts of the world child deaths have become very rare, but differences across countries are high. Somalia – on the Horn of Africa – is the country with the highest rate, 14% of newborns die as children.

The fact that several countries show that it is possible for 99.7% of children to survive shows us what the world can aspire to. Global health has improved, and it is on us to make sure that this progress continues to bring the daily tragedy of child deaths to an end.

Our ancestors could have surely not imagined what is reality today. Let’s make it our goal to give children everywhere the chance to live a long and healthy life.

An earlier version of this article was published in June 2019.

Additional information

Infant mortality rates in the past.

Many of the studies brought together by Volk and Atkinson also report estimates of the infant mortality rate, which is defined as the share of newborns who died in their first year of life.

Across the entire historical sample the authors found that on average, 27% of newborns died in their first year of life. This means the two key estimates are both easy to remember: Around a quarter died in the first year of life. Around half died as children.

The global infant mortality rate today is below 3%. In our map for infant mortality you can find the data for every country in the world.

Mortality at young ages in hunter gatherer societies

The historical data discussed above goes back 2500 years. What about prehistory when our ancestors around the world lived as hunter-gatherers?

Good evidence here is much harder to come by. To study mortality at a young age in prehistoric societies the researchers need to mostly rely on evidence from modern hunter-gatherers. Here, one needs to be cautious of how much we can learn from the realities of modern societies for those of the past. Modern hunter-gatherers are to varying degrees in exchange with surrounding societies and “often currently live in marginalized territories”, as the authors say. Both of these could matter for mortality levels.

To account for this, Volk and Atkinson have attempted to only include hunter-gatherers that are best representative for the living conditions in the past; they limited their sample “only to those populations that had not been significantly influenced by contact with modern resources that could directly influence mortality rates, such as education, food, medicine, birth control, and/or sanitation.”

Again, the researchers find very similar mortality rates across their sample of 20 different studies on hunter-gatherer societies from very different locations: The average infant mortality rate (younger than 1) was 26.8% and the average mortality before puberty, 48.8%. Almost exactly the same as the historical sample discussed above.

All but one of these studied societies are modern hunter-gatherers. The one study on mortality rates of paleolithic hunter-gatherers investigates the famous Indian Knoll archaeological site from around 2,500 BCE, located in today’s area of Kentucky. 12

For this community the estimates suggest that mortality at a young age was even higher than the average for modern-day hunter-gatherers: 30% died in their first year of life, and 56% did not survive to puberty.

Neanderthals and primates – the mortality of our closest relatives

Going beyond our own species (homo sapiens), researchers have also attempted to estimate the mortality rates at young ages for our closest relatives.

Studies that focussed on the Neanderthals, our very closest relatives who lived within Eurasia from circa 400,000 until 40,000 years ago, suggest that they suffered infant mortality rates similar to our species before modernization: it is estimated that around 28% died in the first year of life. 13

Atkinson and Volk also compared human child mortality rates across species with other primates. Bringing together many different sources the authors find the mortality rates of young chimpanzees and gorillas to be similar to the mortality rates of humans of the past, while other primates differ: orangutans and bonobos appear to have somewhat lower mortality rates and baboons, macaques, colobus monkeys, vervet monkeys, lemurs and other primates suffer from higher mortality rates at young ages.

As explained in the following footnote, this data is available from the Human Mortality Database.

Regarding the number of children that people had, the metric that I would ideally need here is the average number of children per woman (or per couple). This is sometimes reported as average family size, but I was not able to find this data. But I could find data on the total marital fertility rate.

The sources for both the number of children and the rate of deaths for the three countries are the following:

Sweden:A total marital fertility rate of 7.62 children per married woman is reported in Table II (page 40) in M. Anderson (Ed.) (1996) – Population Change in North-Western Europe, 1750–1850. Extramarital children were rare in Sweden at the time. Anderson estimates it at 2%.

The under-15 mortality rate is taken from the Human Mortality Database and corresponds to the average of the annual observations between 1750 to 1780.Bavaria, Germany:

This data is taken from John Knodel’s research: John Knodel (1970) – ‘Two and a Half Centuries of Demographic History in a Bavarian Village’. Population Studies 24, no. 3 (1 November 1970): 353–76.

According to his study married women had on average 5.6 children and saw on average almost three (2.8) of their children die before they were 15 years old. Knodel also includes data for an earlier period, but cautions against relying on it, writing: “The figure shown for couples married between 1692 and 1749 is undoubtedly spuriously high, resulting from the frequent omission of infant and child deaths from the parish registers during the period.” Knodel suggests that even the data after 1750 (which is shown here) is likely an underestimate of the true mortality.

France:In France the average married woman had about 8 children in the period 1740 to 1769. This is the total marital fertility rate taken from Table II (page 40) in M. Anderson (Ed.) (1996) – Population Change in North-Western Europe, 1750–1850.

Youth mortality rates for France are reported in Volk and Atkinson. For the period 1600-1700 the authors report an estimate of 40-50%. They also present an estimate for the period 1816-50 when the mortality rate was 44%.

This research is carried out in the area of Pueblo Viejo, Cahuachi, Estaqueria and Atarco in the Nasca valley.

The mortality is quoted after Anthony A.Volk Jeremy A. Atkinson (2013) – Infant and child death in the human environment of evolutionary adaptation . In Evolution and Human Behavior. Volume 34, Issue 3, May 2013, Pages 182-192.

The original paper is Drusini, A. G., Carrara, N., Orefici, G., & Bonati, M. R. (2001). Paleodemography of the Nasca valley: Reconstruction of the human ecology of the southern Peruvian coast. Homo, 52, 157–172.

This research is carried out in several sites on the S’Illot des Porros in Mallorca.

The original paper is Alesan, A., A. Malgosa, and C. Simó (1999) – Looking into the Demography of an Iron Age Population in the Western Mediterranean. I. Mortality . In American Journal of Physical Anthropology 110, no. 3 (November 1999): 285–301. The life expectancy at birth was 23 years.

For details see the paper Anthony A.Volk Jeremy A.Atkinson (2013) – Infant and child death in the human environment of evolutionary adaptation . In Evolution and Human Behavior. Volume 34, Issue 3, May 2013, Pages 182-192.

When relying on evidence from modern hunter-gatherers one needs to be cautious of how representative these societies are of those in the past. This is because recent hunter-gatherers might have been in exchange with surrounding societies and “often currently live in marginalized territories”, as the authors say. Both of these could matter for mortality levels, so that the mortality rates are higher or lower than in historical times.

All but one of these studied societies in Volk and Atkinson are modern hunter-gatherers. The one study on mortality rates of paleolithic hunter-gatherers finds a higher youth mortality rate: 56% did not survive to puberty.

In the literature on global health and modern health statistics, the most commonly studied age-cutoff is the age of five and the share of children dying before they are five years old is referred to as ‘child mortality’. A low age-cut off makes sense because the mortality in early childhood is typically substantially higher than in late childhood. Nevertheless a focus on the first five years gives only a partial view on the mortality of children. Childhood of course doesn’t end at the age of five, and in this article I’m relying on a more common definition of childhood and am considering all deaths up to the end of puberty or up to the age of 15. Which cutoff is used varies between the different studies on which this account is based on.

A higher cut-off also has the advantage that it makes it possible to connect with historical and archaeological research on the mortality of children. Especially in archeological records it is not possible to determine the precise age at which a child died, but it is possible to differentiate between a child and an adult.

The researchers Anthony Volk and Jeremy Atkinson, on whose research I am primarily relying here, have brought together most of the historical estimates I am reporting here. Their literature search focused on the  share of children who died before reaching “approximate sexual maturity at age 15”. See: Anthony A.Volk Jeremy A.Atkinson (2013) – Infant and child death in the human environment of evolutionary adaptation. In Evolution and Human Behavior. Volume 34, Issue 3, May 2013, Pages 182-192.

The mortality up to the end of puberty is less commonly reported in modern health statistics. But it is of course also estimated by health statisticians and at the end of this post you find the estimates from the IGME at:

(Note that Volk and Atkinson refer to the mortality up to “approximate sexual maturity” as child mortality, while I am following the established language in global health statistics where child mortality is reserved for mortality up to the age of five.)

The demographers Toshiko Kaneda and Carl Haub estimate the number of humans that were ever born to be about 100 billion. Applying a child mortality rate of 50% this would mean that about 50 billion children died throughout human history. This is of course a rough estimate, but it gives us some idea of just how many children died.

Despite the great pain caused by poor health and early death humanity discovered extremely few medical remedies and practices that were effective over the course of hundreds of generations.

While the rate of discoveries was extremely slow, there were certainly some breakthroughs that were relevant in the context of the time. One such example is that from the bark of the Cinchona tree Quinine was extracted which was effective in treating malaria. For other drugs see Wikipedia’s List of drugs by year of discovery , which includes some other remedies.

We discuss this in more detail here and also in the first footnote of this article. From 10,000 BCE to 1700 the world population grew by only 0.04% annually ..

Anthony A.Volk Jeremy A. Atkinson (2013) – Infant and child death in the human environment of evolutionary adaptation . In Evolution and Human Behavior. Volume 34, Issue 3, May 2013, Pages 182-192.

See also M.E. Lewis (2007) – The bioarchaeology of children. Cambridge University Press, NY.

The Indian Knoll site was investigated by Francis Johnston and Charles Snow C.E. Snow. See F.E. Johnston, C.E. Snow (1961) – The reassessment of the age and sex of the Indian Knoll skeletal population: Demographic and methodological aspects . In American Journal of Physical Anthropology, 19, pp. 237-244.

And also Indian Knoll skeletons. The University of Kentucky, Reports in Anthropology, Vol. IV, No. 3, Part 11 University Press of Kentucky, Lexington, KY (1948)

The 28% infant mortality rate is reported in Volk and Atkinson based on Trinkaus (1995).

Erik Trinkaus (1995) – Neanderthal mortality patterns. Journal of Archaeological Science, 22 (1995), pp. 121-142. Online here

Chamberlain (2006) also reports very high mortality rates for subadult Neanderthals (Homo Neanderthalensis). See: Andrew T. Chamberlain (2006) – Demography in Archaeology. Cambridge University Press (Cambridge Manuals in Archaeology).

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High Mortality Rate Country: Review

Introduction (why i chose somalia).

After the civil war that saw the toppling of hitherto president of the country in 1992, Somalia has remained in the category of failed states torn by civil war and other natural catastrophes (World Bank, 2009). The country is located in the Horn of Africa to the Eastern part of the continent. Due to the continued state of anarchy, the country continues to record high mortality rates much of which goes unreported due to the ineffectiveness of government agencies (Menkhaus, 2005). Just recently, the country suffered one of the worst famine and drought that not only threatened the lives of the children but also the entire population. In fact, the World Health Organization (2011) says the hunger and famine experienced in 2011 reflected the worst natural catastrophe to hit the country in almost half a century. Over 3 million children faced starvation and malnutrition risking high rates of early deaths (WHO, 2011).


Menkhaus (2005) asserts that Somalia borders Djibouti, Yemen, Kenya and Ethiopia in the Eastern part of Africa. The east of the country has the longest coastline that extends from southwest coastal border of Kenya to the Gulf of Aden. Although the country is largely arid and numerous people rely on nomadic pastoral activities, there are highlands and mountainous regions especially in Shebelle where agriculture thrives (Menkhaus, 2005).

By 2009, Somalia had a population of approximately 9 million people half of whom lived below the poverty line of less than a dollar daily according to United Nations High Commissioner for Refugees (UNHCR, 2009). This implies that the country is highly impoverished and the large proportion of the population is vulnerable to poverty and disease.

Under the rule of Siad Barre, the country was stable politically. Since the political unrest, lawlessness and civil war ensued after 1992 coup d’état , the country has never been under a stable government. Tribal factions have continued to run the country periodically. This has led Somalia to be vulnerable to external forces especially terrorists networks such as Al Qaeda that have continued fund extremist groups such Al Shabaab (Menkhaus, 2005). This has compounded the political instability making the country to be the most politically unstable in the world according to the international center for governance. With that in mind, most of the institutions and government facilities are unable to offer health care services to the population. Health sector is the most affected with only few health care providers, medical and nursing practitioners. The number of health care practitioners can barely meet the health demands making it the major reason for high mortality rates (Menkhaus, 2005).

For over two decades, Menkhaus (2005) highlights that the country’s economy has been unstable since there exists only a handful of effective economic institutions. The informal economy has however flourished with the World Bank records indicating that the country has a Gross Domestic Product (GDP) of approximately $5.7 billion by the end of 2009 (World Bank, 2009).

State of Health

Ministry of Health was in charge of public health sector before the collapse of the nation’s government in early 1990s..Although the provision of healthcare was mainly in the urban areas, the medical officials located in major region of the country enjoyed considerable influence especially in enhancing accessibility to health care services (Menkhaus, 2005). Health care services continue to dominate the health care sector notwithstanding the opposition directed towards them during the reign of Siad Barre. According to Menkhaus (2005), the rationale is that the civil war that erupted devastated and destroyed public health facilities and structures. Private sector constituted mainly by community and relatively affluent citizens run the current medical clinics and hospitals. This predisposes the people to high cost of health care services contributing to high mortality rates in the country.

By 2010, the life expectancy of Somalis stood at 50 and 48 years for females and males respectively (WHO, 2011). The number of children under the age two years immunized against Measles fully is low according to the WHO (2011). Indeed, the report showed that only four out six children have received full immunization from the disease implying that approximately 60% had not received any such immunization. For other life-threatening diseases like tuberculosis and malaria, the children remain vulnerable to infections. Infant mortality stands above 10% implying that about 110 children out of 1000 births die. To compound the already complex scenario, the number of medical physicians remains very low. Indeed, the country had less than fifteen qualified medical doctors. This implies that around 100, 000 people can only access health services from one physician (WHO, 2011). This has created a thriving ground for private healthcare services and unqualified medical practitioners. In addition, only 430 midwives and less than 300 nurses had received training in the whole country insinuating that each of them served at least 1000 people (WHO, 20011). With the civil and political unrest being more of a norm than exception in the country, the nursing and medical schools within the country have failed to provide qualified practitioners to serve in the healthcare sector. The reason behind this assertion is that ‘brain-drain’ is alarming since newly qualified practitioners flee to other countries mainly due to the grave state of affairs in Somalia (Menkhaus, 2005).

Culture and Traditional Medicine

This has created a gap that traditional herbalist fill. While we consider that over 80% of the country’s population live in the rural areas, access to affordable healthcare services remain a huge challenge (Menkhaus, 2005). World Health Organization (2011) articulates that well above 30% of the people receive healthcare services from herbalists as of the year 2010. While many international organizations have been proactive to improve access to medical services, the rise of militia and extremist groups has impeded these efforts. Mainly, the militias have been kidnapping humanitarian workers who take services to the rural areas of the country. Due to the frailty of the government, the country lacks any organization that standardizes the quality of the healthcare services by nurses or any other caregivers. Quack doctors and medical practitioners have been on the rise compromising the quality of healthcare services. These are among major reasons for high mortality rate within the country.

Healthcare System and Delivery

To that end, Somalia ought to prioritize on ensuring that the major international healthcare providers like Flying Doctors and AMREF continue to operate in the country at least for now (WHO, 2011). The rationale is that the country still struggles to have a stable government that would see more practitioners and nurses coming out of nursing and medical institutions to fill the apparent gap in the health care sector. Nonetheless, this would serve as a short-term measure to counter the ever-increasing rates of infant mortality from preventable causes. Besides, there exists no nursing accreditation agency and a nursing council given the porous situation of the country.

Health Priorities

A long-term measure would entail prioritization of preventive care that will lower the number of people in need of health care services considerably. World Health Organization recommends an aggressive sensitization of people on health care services, provision of water and sanitation facilities across the country, setting up institutions where nurses can acquire requisite skills and setting up a body that will monitor and standardize the quality of service provided by nursing professions (WHO, 2011).

Nursing Implications

To achieve these goals and health priorities, the nursing profession in the country will have to expand its confines to prioritize on care provision in the rural areas. It requires the relevant authorities to set up training schools that will produce increased numbers of nurses to offer healthcare services to the people in the rural areas (Menkhaus, 2005). The nursing professions will therefore play an important role of ensuring that the communities in which they serve can access information of preventive care rather than curative care. Lowering the mortality rates requires that a higher number of people access healthcare information that may lead to sensitization. Nonetheless, it is important to notice that all these efforts will be futile if the status of unending civil and military war continue to typify the polity institution of the country. Without a stable form of government, the health priorities will remain elusive since the government will ultimately face challenges in achievement of the goals. It is therefore the role of humanitarian organizations to step in and provide health care services lacking in the country (Center for Disease Control, 2011). This will not only counter the rise of mortality rates but also offset the pressure that the transitional government experiences especially in providing healthcare services to citizens of a war-ravaged country.

Center for Disease Control (CDC). (2011). “Population-Based Mortality Assessment—Baidoa and Afgoe, Somalia”. MMWR, 41(49): 913–917.

Menkhaus, K. (2005). Somalia: State Collapse and the Threat of Terrorism . Washington: Routledge Publishers.

United Nations High Commissioner for Refugees (UNHCR). (2009). “USCIRF Annual Report 2009 – The Commission’s Watch List: Somalia”.

World Bank. (2009). World Development Report: Investing in Health. Washington D.C.: Oxford University Press.

World Health Organization (WHO). (2011). Health Facilities: Overview of Somalia. New York: McGraw Hill Publishers.

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