A story from the field: crude death rates

Note* I started writing this blog post several weeks ago, and then got caught up and didn't finish- but regardless, I think its a story that deserves to be told, so I've finished it and am posting it now.
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The exhilarating and exhausting thing about this job is that it requires me to be part social worker, statistician, social researcher, livestock expert, grant writer, economist, health professional, diplomat, hostess, accountant and administrator. Its Friday night now... this past week has been jam packed with donor visits, assessments, project designs, budget re-designs and evaluations. I've been in UN meetings, planning sessions, workshops, refugee camps, and Land Cruisers. Looks like next week is going to be much of the same. So, this evening, I took some time out to Skype with my people back home. One of my favorite daughters of New Orleans, Madeline B., and I had a great catch-up chat and I promised her that I would post this story. So Maddie, this is for you...

Part of my job is to do assessments. What this means is that I try to determine what the situation is in a particular place, regarding a particular sector of development, for a particular group, at a particular point in time. For example, I would try to answer the question, "right now, in refugee camp X, what is the educational situation like for children?" The point of this is to identify needs so that an NGO can secure funding and start to implement projects to address those needs. It might go something like this:

You look at school enrollment rates and notice that girls are dropping out around 5th or 6th grade at much higher rates than boys. You talk to the school principal and teachers, (key informants), the PTA (focus groups) and girls who have dropped out as well as girls who have stayed in school (surveys or focus groups). Through these groups you learn that girls stop going to school when they get their periods. They don't have sanitary materials to use and even if they did, there are no bathrooms for them to use during the school day. Your assessment identifies a problem and the reason for that problem.
Then, you work on a project design that suggests interventions that may alleviate the problem-- in this case, providing girls with locally sourced, sanitary supplies and building gender segregated bathrooms at schools.

Right now, I'm in the midst of an assessment of basic service needs in the refugee camps in this state. We started looking at water and sanitation, health, education, HIV/AIDS, and gender-based violence as possible areas of intervention. Several other organizations are working here and they have water and sanitation and gender-based violence covered. So, we looked at health, education and HIV/AIDS interventions.
I could probably write 10 blog posts on this assessment... (And since I wrote this post, I did write several) but for now, I'll just tell you about a portion of the health component...

One of the most basic public health statistics is crude death rate. That is, how many people have died per 1000 people, per year? In the US, this is a very easy number to get. The CDC publishes weekly mortality and morbidity reports (MMWR's) which tell you how many people have died and what the causes of death were. The CDC can do this for a few reasons.
1. They are funded by a government who thinks statistics like this are important.
2. That government has citizens who have the capacity to collect and manage data like that.
3. When people die, we keep records. Bodies are not buried in front yards (in fact, that's illegal). They go to morgues and funeral homes and it’s all neat and tidy and documented.
4. Unless you're trying to keep collecting on Aunt Mildred's social security check, there's no real advantage to NOT reporting a death.
5. The system works at all levels. Town, County, State, Federal etc. It’s organized into a clear, standardized reporting hierarchy.

This does not happen in South Sudan.

It especially doesn't happen in refugee camps.

There is no neat system chronicling the births and deaths of people who live in these camps. If you happen to die in a health clinic run by an NGO, then someone will probably record your passing. But, if you die at home, as the majority of infants, children and women do, then no one documents it. If your family is very poor, they may appeal to the NGO who runs the camp, (this would be an opportunity to collect some mortality data, sometimes it happens, sometimes it doesn’t) to ask for some money to purchase cloth with which to wrap the body and some tea leaves and sugar to serve to mourners who attend the funeral. Then, there would be a 3 day funeral and the body is buried in a grave on the family plot. Zande graves are marked with a domed structure, resembling the tholos tombs at Mycenae, though much smaller in scale. (… even as I write this, I realize how dorky it is that I both know and have used this term… and that visiting Mycenae was one of the coolest things I’ve ever done). The great disadvantage of getting assistance from an NGO for the burial is that they might record it. This means, that when the next month’s rations are distributed, you will be noted as having one less person in your household, and will get proportionally fewer rations. So, if your family can scrape together the money (about 10USD) to buy cloth and tea leaves yourselves, it’s preferable and economically advantageous. Then there is the third category of refugees—those who can manage to find 150 Sudanese Pounds (around $30) and pay to have their loved one transported back to Congo. If you’re paying attention, this should raise all kinds of questions:
First, if Congo is so dangerous that these families had to flee for their lives, who is the poor schnook who is risking a trip, back to bury a body?
Second, there are no real roads between most places in Congo and South Sudan. To get anywhere, one has to travel on long, hot, bumpy and dusty (or muddy depending on the season) roads— on a motorbike. This is difficult enough with one rider-- uncomfortable and dangerous at best with 2 live riders. I can’t imagine the nightmare of transporting a dead body through the equatorial jungle on the back of a motorbike. How is this done?
I have discovered the answers to both of these questions. The first is someone desperate.
The second is that one wraps a body up mummy-style, ties it to a plastic lawn chair, and ties the chair upright on the back of the motorcycle and goes. I was absolutely convinced that someone was pulling my leg when they told me this. I had to ask 5 different people to confirm. And, yes, apparently this is true, unbelievably true.
So, back to my original point... all the skills that we learned in grad school about careful data management, statistical power, confidence intervals, etc. mean jack when you are faced with a corpse on a motorcycle... that's when you have to start getting creative.

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Sorry for the lack of photos on this post... I’m swamped at work right now, both of my immediate bosses are out of the office and I’m “Acting” for both of them. Plus a colleague of mine is out, so I’m doing her job and I have to do my own job—This is the kind of stress I was made for!!!! Signing off from Yambio, J