How I Learned to Understand the World

by Hans Rosling

  In this case, to emphasize the danger ahead, the workmen had added a half-meter-high mud wall running across the road. In this part of Mozambique, the soil is a deep reddish-brown. I was always amazed to see how lovely bare, wet earth looked at sunset.

  We had been zooming along in the darkness. Our driver missed the first warning and when I caught sight of the roadblock, we were just thirty meters away from it. I simply howled, unable to find the words in Portuguese.

  All our driver had time to do was to twist the wheel. Then he lost control, so that when the car crashed into the mud embankment it was already in a skid. The car rotated and leaped into the air at the same time with a momentum so powerful I was subjected to a centrifugal force. I did not feel upside down, even as the world turned. Green grass up there, dark starry sky down there.

  We flew through the air. I’ll die now. I had time to think these words.

  Seconds later I was amazed not to have been crushed. The impact had not come. Instead, the car kept gliding on its roof like a surfboard on water. The wet grass and soft mud did nothing to stop it. The forward movement made me shoot out through the gap where the windscreen had been and then continue sliding on my back. Nothing made sense. A few moments later and I was lying quietly in the tall grass. I slowly pushed myself upright with my hands and found myself staring straight into the beams of the headlights. The car’s engine was still running.

  My mind fixated on my right foot. It was bare, and the nail of the big toe had gone. My left foot was still clad in its sock and shoe. Almost without thinking, I began to walk toward the car. I came across my right shoe. I put it on. Then I spotted my glasses and put them on. Then, for the first time, I thought about the car. The light glowed, the engine was turning and it was upside down. It will catch fire and then explode, I thought. I had seen what happens in films. Cars overturn and a little later they explode.

  So far, I had not had time to reflect on being, seemingly, in one piece. I went to the driver’s side, saw it was empty and stuck my hand in to turn the ignition off. Silence fell.

  A calm voice spoke near me: “Why turn it off? It’s completely dark now.”

  It was a doctor from one of the other districts. While I had been getting up from the grass and putting on my lost shoe, he had crawled out through the rear door and been able to talk to the others. They were also all right. We noted that the driver was gone. He had run away.

  “Three of us have got away with only minor injuries,” my colleague said. “They are sitting behind the car.”

  Now we heard wailing from inside the car. Ana Edite was stuck in there, under our sacks of flour and avocados, squashed up against the roof bars. Our shopping was scattered all over and around Ana and our first thought was to get her out by getting it out. We tried to push the car from side to side but Ana screamed in a way that made us realize that was a terrible idea. Then it struck me that we could dig her out of the soft mud. I dug with the help of a key I had found in a pocket. When she had unstuck a little, we slowly pulled her forward, feet first.

  Then we stood there in the middle of the night. It could be half an hour between cars on this road in the Mozambican countryside.

  The people who lived in the huts on the other side of the road came out with paraffin lamps so we could have a closer look at people’s injuries. I examined Ana, who said she had bad abdominal pain on the left side. I understood that she was bleeding internally, as I sat with her, checking her pulse while we waited for a car. Her pulse rate was increasing, as it would initially if the patient was losing a lot of blood.

  I looked for damage on her body, including on her fingers and face and under her hair. I couldn’t find anything and could not do anything for her. This is a matter of luck, I thought. If she is unlucky, she will die quickly. If she is lucky, we will get her to a hospital in time.

  “They are on the way, and they’ll take you to Nampula,” I told her, to calm her down.

  “My husband, you must get in touch with him,” Ana said.

  Then a car did come along. One of my colleagues, who was only a few kilometers from his own hospital in Monapo, knew the family in the car. Later the same night, Ana Edite was on the operating table. She had years of rehabilitation to come, and a poorly functioning foot that she would have to cope with for the rest of her life. But she survived.

  I had been so grateful to the villagers who had crossed the road to light us with their paraffin lamps that I tried to give them a sack of avocados as a thank-you gift. A crazy idea, Ana Edite’s husband told me much later. Every one of them was a small-scale avocado grower, he explained, laughing heartily.

  I cursed myself that night because by helping to arrange the transport I had broken a rule I knew only too well: you should never drive at night in a poor country and especially not after heavy rain. I had lost several friends that way. However, it was a relief to know that Agneta was not waiting anxiously for me at home. She did not expect me until lunchtime the following day. I slept at my colleague’s house, and in the morning washed my foot and rinsed my torn shirt.

  When I was dropped off outside our house, Agneta was standing in front of the open kitchen door, smiling. Tears welled up in my eyes as it struck me how close to death I had come. We stood, holding each other tightly, just inside the door. But that intense moment was not to last because there was a knock on the front door. Irritated, Agneta went to see who it was.

  In trooped the Grupos Dinamizadores, the local group of Party reps. They turned up on people’s doorsteps on Saturdays to check that everyone had tidied up properly. The point was to avoid being found out as a xiconhoca—that is, a filthy counter-revolutionary who was probably trading on the black market.

  Agneta tried to explain that this was not a good time for an inspection but the Grupos Dinamizadores paid no attention to her. They told me to go and rest in bed instead of standing there trying to explain things to them, so I lay in bed sobbing while they poked about all over the house. In the end, they took an interest in only one thing: the sack of avocados. This was understandable, because it was an unusual find: we had never during our two years in Nacala been able to buy avocados in the town. Had we acquired it on the black market?

  As this utterly absurd night and day drew to a close, I was struck by a fact that would become critical for our entire continued existence in Nacala. The thought crept into my mind when I had calmed down after a few hours at home: Ana Edite would not be coming back to work. I would be the only doctor in the whole district. I would be on call round the clock.

  The health service’s resources were already minimal and the care needs maximal. From that day on, as I went to work in the mornings, I thought more and more often about how different the health statistics were in Sweden. My thinking followed these lines: “Today, my day’s work will be the equivalent of the work of a hundred doctors in Sweden. What am I to do? Examine each patient a hundred times faster or pick one out of every hundred patients?”

  Every day, I somehow had to find a compromise between these two options.

  As a matter of fact, very many sick people never saw the inside of any care facility, let alone the hospital. True, it was rather small with its fifty or so beds, which were always full. Some inpatients even had to lie on the floor. Still, what care we could offer was not limited by the number of beds. The real limitation was us, the staff—in quantity as well as quality. I had a little more than two years of professional experience. The handful of Mozambican nurses had four years at school and then trained in nursing for one year. More than half of the rest of the staff were illiterate.

  If this had been Sweden, I would have been one of a hundred medics responsible for the care of this population. Also, the child mortality rate would have been a hundred times smaller. My challenge now was to get a grip on what our resources actually were and how to use them in the best possible way. Beyond the hospital, it was harder still to get my head around the nearly nonexistent care resources for the rural population. Practi
cally all of them lived in conditions of extreme poverty. Their strength and energy were concentrated on finding enough to eat and, even then, there were many days when they would go without.

  Again and again, I was forced to recognize how unrealistic my ambitions were. Everyone, patients as well as hospital staff, tried hard to show me what was possible and reasonable. It was very far below the level of expectation that my Swedish medical education had instilled in me. A need one hundred times greater than in Sweden had to be met using one percent of the resources. That meant about ten thousand times less resource per patient. Ten thousand!

  I admit that trying to adjust to and cope with this differential felt like being in a post-traumatic state. I called it “my four-zeros brain trauma.”

  * * *

  The psychological state of generalized scarcity taught me lessons about myself. I had previously thought that I led my life guided by certain unshakable values. I believed, for instance, that you must not kill a thief. That is, until I was pushed beyond control. One night, someone unscrewed the headlight covers on one of our two ambulances and stole the bulbs. Now that ambulance could not be used after dark. That theft filled me with an explosive hatred. I fear that I might have killed the thief if I had caught him. Just as I might have killed the creep who stole our ducks.

  In a school room, with the children

  The children enjoyed the ducks but our main reason for keeping them was to have a small but valuable source of meat in a centrally managed economy with erratic supplies of food. One night, the ducks were screeching so loudly that the row woke Agneta. She looked out through a window and saw someone breaking into the duck house. She called out and the thief ran away. I jumped into the car and chased him. When I spotted him in front of me on the road, I put my foot down and followed him around a corner. An echo was bouncing around in my head: “That bastard won’t get our ducks.” Until I realized that I was about to run him down and kill him. I must pull myself together. The thief slipped into a side path and disappeared. He was lucky. The judicial system was failing and people often took justice into their own hands, sometimes brutally. Theft caused immeasurable damage to people and the punishments could be vile. One common method was to tie the thief’s hands behind his or her back with lengths of rubber cut from inner car tires. Unless someone cut the straps quickly, the blood stopped circulating and the hands became permanently useless. I had quite a few people with tied-up hands coming into the hospital and was normally furious at having to waste time on them.

  The cruel dangers of living in extreme poverty were also reflected in other injuries we had to deal with in the hospital. The town had only one shop which sold food, the loja do povo or “people’s shop,” and its shelves were often empty. Now and then, it got a consignment of fish, which was sold via the loading bay because the goods entrance had a big steel door. The pressure of the crowd of customers would have been enough to break the display windows if they had traded as usual. Instead, the shop manager opened the steel door and admitted some fifty people at a time. The crowd soon became chaotic, and someone always got badly squashed. On days when several bone fractures were queuing at the hospital to be fixed, we knew that the state shop had been selling fish or sugar.

  * * *

  The car stopped outside our house and our Swedish friends were still laughing as they climbed out. It had been easy to find us.

  “We did just what you said and asked people where the doctor lived. They all pointed to the right place at once!”

  They were a couple of about our age who had come to stay with us for the weekend. The same organization that had recruited us had recently arranged for them to come to Mozambique and work in the large regional hospital in Nampula, two hundred kilometers from Nacala. The husband had a post as the pediatric doctor on the neonatal unit.

  It was fantastic to have visitors. We were hungry for conversation and especially keen to talk to people who could understand how we lived now. Lunch went on and on because we had so much to discuss. We spent a lot of time comparing our places of work.

  “Honestly, none of my nurses have any specialist qualifications,” he told me.

  “Half of my staff can’t read,” I said. And so it went. We kept talking past each other in a rather male way.

  We unquestionably worked with very different levels of staffing and equipment. That was how it had to be, because the regional hospital also taught clinical students, so the care had to be of a reasonable standard.

  Our talk was interrupted by an energetic knock on our front door. Because the telephone was out of order, a nurse’s assistant had walked from the hospital to fetch me. A very ill child had just been admitted.

  My friend borrowed a white coat from me and came with me in the car. When we stepped into the small room for acute admissions, we met the terrified eyes of a mother trying to breastfeed an emaciated infant. The baby girl, who was only a few months old, was almost unconscious and her eyes were sunken. Bad diarrhea, the nurse told me. When I pressed the skin over the child’s belly using two fingers, the fold persisted long after I had taken my fingers away. The diagnosis was obvious: she was dying from dehydration and was too weak to suckle. I took a thin tube, introduced it via her nose into her stomach and told the nurse which type of fluid replacement to use and how much.

  My friend was shocked. When I was almost done, I felt his hand gripping my shoulder and he pulled me out of the small room, stopped outside in the corridor, and looked at me with an infuriated expression.

  “What you just did was utterly unethical! That baby did not get the right treatment. You’d never have done it to your own child. She was very sick and should have been hooked up to an intravenous drip immediately. You are risking her life by giving rehydration solution via a nasogastric tube. She could start vomiting it up and lose the water and salts she needs to survive. I suppose you’re taking the quick way out because you want to get to the beach before supper.”

  He was unprepared for the kind of medicine that the brute facts had forced me to accept.

  “No, what you saw is the standard treatment in this hospital. This is how we work. We never do better, because of the resources and the staff we have. And that includes me. I have to get home in time for supper at least a few evenings every week, otherwise neither I nor my family would make it through another month. It might take me half an hour to get a drip set up for this child. And there’s a high risk that the nurse won’t be up to keeping an eye on it and the baby will get no fluid at all. But the nurse can do tube rehydration, it’s more straightforward. You must accept that our level of care is only as good as possible.”

  “No, I can’t,” my friend insisted. “It is unethical to manage that baby with fluid fed by nasogastric tube. I am going to put her on an IV drip and you can’t stop me.”

  I didn’t stop him. Instead I brought him the thin needles suitable for the veins of small children. We had saved some up in a cupboard in the doctors’ office. Despite many attempts, my friend could not get a needle into any of the baby’s veins. Next, he wanted the necessary equipment for incising, to expose a deep blood vessel. He set about this minor operation and our nurse did her best to assist him. I left them to it, went home and had supper with my family and my friend’s partner. My work recently had been relentless and I had not eaten an evening meal at home for several days.

  Afterward, I drove back to the hospital to pick up my friend. After much effort, he had finally got the drip up and running. The baby seemed a little better but still would not suckle.

  That evening brought no rest. Once the children were asleep, my friend and I sat on the sofa and talked deeply and very honestly about the ethics of what we were doing.

  “You must always do your best for each and every patient who wants to be seen,” he said.

  Numbers are so important in ethical discussions. It is misleadingly easy to define what is right and wrong when you speak about one patient at a time.

  “I don’t think so,”
I replied. “It is unethical to spend all available resources, including time, on trying to save only those who have been admitted to the hospital.”

  I went on to explain that more childhood deaths would probably be avoided if I spent more time on improving health facilities at street level—that is, care in local health centers and small clinics. My task must be to do all I could to improve child survival and health in the entirety of the town and its surroundings. I had become convinced that most of those who died from preventable causes had stayed at home and never come to the hospital. If we were to concentrate all our resources on making the hospital as good as possible, fewer children would be vaccinated, fewer competent members of staff would serve in the existing health centers, and the effect would be that, overall, more children would die. I was as responsible for the children I did not see suffer and die as for those I did see. Given our poor resources, I therefore had to live with the low level of care we offered at the hospital.

  My friend disagreed, as most hospital doctors—and probably the majority of the public—would. He insisted that a doctor must do everything in his or her power for every patient they encounter.

  “The supposition that you might be able to save more children somewhere else is simply a cruel theoretical guess,” he said.

  At about this stage in our debate, I stopped arguing but thought: “It cannot be more ethical to act on your instincts than to make a thorough investigation into how and where you can save most lives.”

  This thought stayed with me throughout the following day, as I tried to help a woman give birth. Her labor was into its second day. The baby was stuck. Its arm had been jammed and someone had tugged at it in an attempt to get the baby out. Now, the arm had grown dark for lack of blood supply. The hand was ruined and would have to be amputated. I could pick up the fetal heart sounds, so the child was still alive, but the mother was running a high temperature. Her uterus might rupture at any time.