Are you a ‘numbers person’, or a ‘words person’? Would you prefer to play Rummikub, or Scrabble? Does Sudoku catch your attention ahead of a crossword? I think preferentially I would be a ‘words person’, but I have come to appreciate the power of numbers as well.
We are being bombarded by numbers right now, thanks to Covid-19. We get cases and deaths, active cases and recovered cases, the number of people in hospital and intensive care. We are watching carefully for increases and decreases and, learning about more complex numbers like, the reproduction rate. Too many numbers can be overwhelming, but numbers have the potential to be a compelling way of understanding the extent and severity of a problem.
One day in the heat of summer in 2011, I took the monthly figures into the Managing Director’s Office in rural South Asia. He exclaimed, “We have an epidemic on our hands!” There had been 40 people attempted suicide by taking pesticide poison. This was only our fourth month of data collection so I could not say it fitted the definition of an epidemic. Seeing the reality of those numbers on the page, spurred him and others into action. The Whole Person Care team and the chaplains became more involved. We had a psychologist join us who could do a more detailed interview, analyse the data, and publish it.[1] Later the community health team became sensitised to the issue, not only of suicide, but mental health in general and developed an excellent community mental health team. Then we had a psychiatrist arrive; the only psychiatrist for five million people. And now I am back to numbers!
Numbers add weight to a story. People had been saying we were having lots of patients with pesticide poisoning but seeing the 40 number, started to drive the assessment of the situation along. It meant there was more than one case per day, and after one year of collecting data we discovered that it was almost 10% of the adult medical workload of the hospital.
During my time in that setting, I was able to start a variety of surveillance systems. Some people think that surveillance numbers are boring and wonder about the point of sending the MS Excel sheet off each week. It’s when you get the aberrations to normal that surveillance really becomes useful. When you report positive laboratory identified cases of Japanese Encephalitis (JE), it enables the children in your district to have JE vaccination available for prevention of this deadly and debilitating illness. It means you get taken seriously by the state surveillance officer and then get invited to additional training to tackle topics of local interest. Never underestimate the power of numbers.
Maternal death surveillance is always a challenge in cultures where shame is the major driver of behavioural patterns. People are prone to see reporting a maternal death as a system that is out to shame and lay blame on individuals. This leads to data being hidden and makes it difficult for improvements to the system to be identified. The motto we developed was, “ek sankhya, ek awaz”, which means, “one number, one voice”. This was designed to help people see beyond the possibility of them being shamed in a maternal death review, to the fact that each case we reported, was one woman we were advocating for who could not speak up for herself. I think some people caught on. Others were going to take longer but I was thankful for the ones who caught on and began to be change agents themselves.
In public health, both numbers and words matter which is why I am writing about numbers in a Healthy Words blog. Maybe next time I will write about words!
[1] Sangeeta Nair, Lois Joy Armstrong, and Philip Finny, “Family Conflict – The Major Underlying Influence in Suicide Attempts in Northern Bihar, India,” Christian Journal for Global Health, May 29, 2015, 23–34, https://doi.org/10.15566/cjgh.v2i1.52.
