Awkward CNAs: This is Global Health

Attemping a seasonal disease calendar to trying unsuccessfully to  pinpoint when clients are getting sick. Just part of the experiment that is a CNA! Also you can tell that I descend from teachers in this picture (Grandfather, Grandmother, Mother, Father who taught college Engineering for a semester, Aunt, and most of my Italian 2nd and 3rd cousins in Delaware)!

Attempting a seasonal disease calendar to try (unsuccessfully) to pinpoint when clients are getting sick. Just part of the experiment that is a CNA!
Also you can tell that I descend from teachers in this picture (Grandfather, Grandmother, Mother, Father who taught college Engineering for a semester, Aunt, and most of my Italian 2nd and 3rd cousins in Delaware)!


You have heard me mention a lovely document called a Community Needs Assessment (CNA) over the past…3 months. After a gracious extension (Ngiyabonga Khakulu PCSA staff) I turned it in on the 29th. Why did I spend a good portion of my integration period working on it? Peace Corps Policy! No, my real answer is that South Africa (well most countries with PC programs but especially the Africa region) does not have a nice history of foreigners (white people) coming in and doing beneficial projects. I do not want to be that white person nor does Peace Corps want me to be a “great white savior.” The way we attempt to prevent this is to do projects that have a demonstrated community need. The way Americans establish need is through mathematics, specifically statistics. My alma mater values sustainability especially in an international context and now it is one of my main goals for service. It will be a challenge to develop projects that can transfer over…and that just is based on the Community Needs Assessment.

One of the perspectives I use to view this South African life, is my experience as a public health student with psychology roots. As an undergrad, I was a Teaching Assistant for an Epidemiology class, which is the action movie of the public health genre. It is the study of epidemics or directly from Greek “What befalls the People” aka disease. The way we usually study disease is through statistics and investigation. If I enjoyed math more, I would seriously consider being an epidemiologist just for the investigation. Epi (as we affectionately call the field) works great…when you have the data available.
Many of my friends who read this blog also share an interest in the global health field. I may use my lessons learned for another project that may surface later on, but I wanted to a lesson learned: when you do not have a baseline population epidemiologic formulas do not help you!

One of the tasks requirements of the report was to have a prevalence rate specific to our community. Prevalence is a measure of the total number of cases of a disease in a percentage. Below is a formula from the Center of Disease Control’s Website:

Prevalence= (persons with a given health indicator during a specified time period /
population during the same time period) X 100

Prevalence is one of the less complicated epidemiological equations to calculate. However it is very time specific, and you cannot have a prevalence rate without a baseline population. Also if a prevalence rate is very high, most public health professionals double check.

If you have say depression in 60% of all Fort Lewis College students in a campus wide survey with a 75% return rate (most people who got the survey actually were nice enough to honestly respond), there will be a massive shift of resources to prevent lawsuits. The vast majority of prevalence rates I have seen are below 50% in large populations. If you were looking a food-borne outbreak linked to homemade ice cream at a church picnic (one of my college Epi assignments) then you may have high rates but there are better formulas for that situation. Still South Africa has the highest number of HIV+ people in the world, because the population is so large. Swaziland and Botswana have the highest prevalence rates in part because of their small population.

Also prevalence is total number of cases of a population, not just new cases. New cases are used by incidence…which is the same formula except you are only counting new cases.

Are y’all still with me? Good. Now you know what the newspapers actually are talking about (and sorry if I ruined the morning coffee).

Now picture trying to figure this rate for your communities (South Africa’s statistics were generous for the district, uThukela has roughly a 37% prevalence rate) when there is no data. My friend (the Nutritionist) who lives in a township by Pretty City literally did not have any data. Being the awesome PCV he is, he raced around uThukela District trying to figure out his community’s HIV prevalence. His local clinic told him to go to Department of Health in Pretty City and he did so, only to be told no. In my case I had a spontaneous meeting with Department of Health Officials at my org. They graciously offered to send me these rates but never did.

Does it seem irrational? In American minds that is public information…as long as it does not feed panic. Well not if you remember that this country had 40 years of a government policy fueled by racism and enforced by demographic information. Even a basic demographic question triggers memories of apartheid. Like yesterday when I asked when my host Gogo’s birthday was and Mama was confused about what day in December. There was the actual day of birth but when she applied for an ID, they changed the birthday by mistake. At least she has a month, many of my org’s clients have January 1st as their birthday because they did not know the actual day and the government unceremoniously assigned one to them.

I like my birthday, and do not blame the current government for being hesitant to give out that information.

I was fortunate as my org is part of the hospice association and we track things like TB and HIV diagnosis. However the last South Africa Census was done in 2011. I kept asking locals if the municipality (which is about to merge with the Social Worker’s come March because it needs additional support) would have a basic population of my valley but people a. did not understand what a population (how many people are in the community) was and b.) Did not think that the government would have anything. Since my org was swamped, I did not have a chance to bother the tribal authority.

Could I have calculated prevalence for 2015 based on a 2011 baseline population? You can stick numbers into any formula but for me that is public health malpractice. On the same lines I could have used our entire data base of active clients as the base line, but then my prevalence rate would be large as most of our clients have HIV. That does not tell me anything that our carers are incapable of sharing: there is a lot of HIV in our valley.

With my circumstances I just counted the HIV + cases and advised the Nutritionist to do the same. It is not perfect but it states that HIV is a problem in our community and we can learn as CHOP volunteers here.

My CNA would have been “C’ worthy in graduate school. However I got my feedback from PC staff today. I was convinced that they would ask me to edit my CNA, but they liked my work. One less thing I have to contemplate! I think the point of the CNA was to gain an appreciation for how hard it is to get information out of communities especially about the judgmental topic of HIV/AIDS. In that case I learned a lot…good job Peace Corps!

I will close with the most generous lesson of all: CNAs are not stagnant as new information and needs arise. Two days after I submitted the CNA, I was in a meeting with my supervisor where she informed me that one of the primary schools in the lower valley had a 56% pregnancy rate. Primary ends at grade 7…and I am not going to lie certain expletives ran through my head. EISH. How did I miss that information?

Once the school holidays are over (mid-July), you can bet that I am going to investigate if actually over half the school girls are actually with child (56% is a very high prevalence rate).

That and maybe I need to lower my standards on prevalence.

Another PCV milestone completed.

All the best,


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