by Hans Rosling
I examined her and realized the baby’s head had engaged in the birth canal. I could feel it just a few centimeters up. I had to hurry.
As a delivery progresses, the clinician—usually the midwife—has to check various functions hourly and enter the data into a so-called partograph. I had made my own partograph with a rule in mind that said: the sun must never rise twice on a woman giving birth. My version was a sheet of paper painted black for nights and left white for days. On the ward round, you tore off a piece of the day or the night. When the sheet of paper was gone, you had to act.
Labor that was continuing when the third twenty-four-hour span was about to begin meant declaring war—the baby must get out somehow. The mother was correspondingly a war victim requiring emergency surgery, and I was a war medic practicing the medicine of the disaster zone. My job in Nacala forced me to work in that spirit from time to time.
“Now what do I do?” I thought.
It was clear to me that I was going to have to kill the baby to save the mother. More specifically, I was going to have to carry out an extraction by dismembering the fetus. I had no proper instruments so I went in with a closed pair of scissors and drove their tips into the fontanelle. The skull came apart and the fetal brain fell out. The baby was now dead. I applied clamps to open up the passage and managed to get the child out, arm first, without the mother’s uterus rupturing. Next, it was crucial to fix a catheter in her bladder. Otherwise the mother ran the risk of developing a cloaca—a breach in the wall separating the vagina from the anal canal, which would allow feces to pass out through the vagina. One usually fixes the catheter by inflating a balloon once it is inside the bladder, but this time I had to be very careful. I used stitches to hold it in place.
The mother was looked after as carefully as possible. And she made it. When well enough, she returned home to her other children. However, having to kill a viable full-term fetus in order to extract it and save the mother is very demanding and very challenging. Did I make the right decision?
Yes, it was the right thing to do in this case. Learning how to make such judgments is hard but it is much harder to act accordingly. Labor is especially dramatic. When the process begins, you are with a healthy woman longing to see the child she loves. Forty-eight hours later she is in deepest hell and close to death.
What to do for her? And what not to do? To dare to make these decisions in the moment, it is crucial that you have explained to yourself exactly which principles you will act on: why your choices will be such as they are. I was appalled at what I had had to do to save this mother, but I knew it was the right decision.
At the same time, thinking back to the dehydrated baby of the previous night, I recognized that, for me, it had become a grim necessity to compare the number of deaths in two groups of children: Nacala children who had been brought to the hospital versus those who were kept at home. Despite our limitations, we had improved the care we offered those who were seen in our hospital, and the proportion of children dying was slowly declining. People seemed to have noticed this, because the number of children we saw was steadily increasing. Most of them suffered from life-threatening conditions such as malaria, pneumonia, and diarrhea. Often, they were weakened by malnutrition, which was far too common, as well as by anemia due to hookworm infections.
Over a year, about a thousand children stayed in the hospital, roughly three new inpatients every day. The others were treated and allowed to go home. All the children admitted were severely ill and, of that group, one in every twenty died despite our best efforts. In other words, a child’s death was a weekly event in the hospital. Almost all of these deaths could have been prevented if we had had more staff and more resources.
I shall never forget what it was like to try to save young lives from the four most dreaded child-killers: pneumonia, diarrhea, malaria, and measles. How we could have just minutes to get enough saline solution into dehydrated children with diarrhea before it was too late. How intensely I hoped that the intramuscular injections of penicillin would be given in time to save young patients with pneumonia.
Even so, my most powerful memories are of the unconscious children suffering from advanced malaria, an illness that in the course of a day can turn a healthy child into a terminally ill patient. Would our injection be enough to save them? They often needed intensive care of the kind we simply could not give them. During the day, a never-diminishing queue of sick children and their relatives snaked across the hospital yard. The hot unshaded space filled up with mothers holding their suffering children, waiting for them to be examined. Often, one glance was enough to grade their state of health: some children were sitting upright while others were utterly limp.
Doña Guita, the only one of our nurses to have six years of school education and two years of clinical training, sat at the front end of the queue. She was a star. Her task was to place every child into one of two groups: ill but well enough to go to the waiting room, or very seriously ill, in need of a hospital bed and often running a very high temperature. The second group needed immediate treatment and were sent across the yard to the emergency reception.
The mother’s eyes often revealed the extent of her worry. When her child was so weary it would no longer breastfeed, a mother’s gaze held only desperation and fear of death.
We had thermometers and always recorded temperatures; some children with malaria had a fever of almost 106 degrees, significantly higher than a normal body temperature of 98.6 degrees. I would ask about the breathing and the mother might say, “The breathing is fine, only my child is so hot.” I learned the key phrases in Makua. He coughs blood. Tummy hurts very badly.
It was important to look properly at the child. Not being able to make eye contact was a bad sign. I crouched in front of the mother, or sat on a low stool, carrying out the examination while she still held her child. It reassured the mother. I wanted the contact between me and the mother to be as close as possible and asked her only brief, calm questions.
Mostly, the diagnosis was malaria. It could become life-threatening at terrifying speed, but the right medication could turn it round in a few hours. Pneumonia behaved in the same way.
I have a strong memory of one particular late session in the emergency reception room. It was raining outside. A despairing mother held her two-year-old son in her arms. The father, who looked just as sad, stood next to them. The little boy was breathing very quickly, had a low hemoglobin value and was extremely pale. He would not get well unless given a blood transfusion as well as medication. But the hospital did not have a blood bank or any other resources for collecting blood from anonymous donors. When required, we would take blood from a relative with a blood group that was compatible with the patient’s.
“But I can’t give blood to my child,” the father said.
“Why not?” I asked. We were pressed for time.
“Someone in my family might need blood.”
I was at a loss. As luck would have it, Mama Rosa, the wise midwife, was standing in the doorway behind me and could explain. Their society was matrilineal and one outcome of this was that the mother’s family—usually the mother’s brother—was considered responsible for the child. At that point, I found it hard to grasp the strength of this social structure.
“But he has many uncles and I know they will give him blood,” the father said.
I freaked out. “Come on, can’t I test your blood all the same?”
Mama Rosa explained that arguing was pointless. The father would never accept donating blood to his son. In his eyes, his son belonged to another family, and it was unhealthy to pass blood on to another family. I capitulated.
The father hurried out into the rain. It did not take long before he and two sweating, soaked uncles came running back. One uncle’s blood group matched his nephew’s. Ten minutes after the transfusion, the child’s respiration calmed down and he began to cough. Just a few hours later, the fever started coming down.
* * *
; Much of what I did at the hospital in Mozambique was actually public health oriented. Ward rounds can be enormously powerful if you talk to the patients in a way that will make them broadcast your ideas when they go back to their villages. In many parts of the world, going to see the doctor provides conversation fodder for weeks.
To me, it had become a matter of my identity: what was I here for? To cure just the patient in front of me, or to improve the health of the whole community?
* * *
I decided it was time to work out the right approach by analyzing the matter numerically. I would collect data in an interview-based investigation. To make it manageable, I decided to focus on the number of children who died in Nacala city and exclude its rural hinterland. This was because there were three health centers in the city itself and, even if most of the population lived in very meager conditions, most of them could get to one of the centers and be referred to the hospital, or else go straight to the hospital emergency unit if a child was suddenly taken very ill.
That evening spent discussing ethics with my colleague from the regional hospital in Nampula had made me feel this investigation was imperative. I had some rough approximations, using already existing information. The 1980 census showed that Nacala had 85,000 inhabitants and that some 3,000 babies were born every year. A total of 946 children had been hospitalized during the past year and of those, fifty-two had died, despite receiving the best care we could offer them. Almost all of the children admitted to hospital were under five years old.
My next question was how many children under five years of age were dying at home, never making it to hospital? The under-five child-mortality figure for the whole country was 26 percent. The latest census gave us the number of births in the city, roughly 3,000 per year, yet the population of the district was five times that of the city, so we estimated there had probably been five times as many births: 15,000. Twenty-six percent of that number gave us 3,900: the number of child deaths I was responsible for trying to prevent. Despite the fact that one child died every week in the hospital, it was a fraction of the total: I was seeing only 1.3 percent of the children I needed to help.
Talking to the hospital staff, I learned that many children were not brought to the hospital when they fell ill. The main reason was apparently that the families consulted “traditional doctors,” who were available round the clock. The alternatives were either one of the town’s health centers, open only during the working week, or an emergency hospital admission.
I planned the investigation together with Agneta, who was working locally as a midwife and was also in charge of the childhood vaccination program that we offered regularly in different areas of the town. By then, our friend and colleague Anders Molin was around to share the work with us. Anders had trained in Sweden and been placed in Nacala. Now the town had two doctors, which made a huge difference to us. Anders shared our quarters and became yet another titular uncle for our children. To me, his presence meant an invaluable lightening of my workload.
Our very limited resources meant that the plan had to be very simple. We chose an area of Nacala called Matapuhe, which, according to the census, had a population of 3,700. Next, we arranged meetings with the community leaders and asked for their help in organizing the study.
In the summer of 1981, a group of seven interviewers, all members of our healthcare team, met local women of child-bearing age. The important numbers we wanted were the total number of births and child deaths over the previous twelve months. Most of the women had no schooling at all and did not count time in calendar months, so we used another way of establishing dates: we did the interviews in the holy month of Ramadan, allowing the mothers to recall what had happened in the twelve months since the last Ramadan. We were careful of our manners and how we expressed ourselves when we asked these delicate questions.
It went quickly and well, perhaps especially because, at the same time, we ran a small treatment unit for ordinary health problems and also offered vaccinations for the children. The ready availability of healthcare encouraged participation and attendance. Once I had the data, I extrapolated for the whole town on the assumption that Matapuhe was a relatively representative area.
The outcomes were very clear-cut, beyond any doubts or fuzziness. In one year in Nacala town fifty-two children had died in the hospital and 672 at home: more than ten times as many. An arguably even more important observation was that, of those who died at home, about half had not been taken to any care facility in their last week of life. In other words, we had shown a need to organize, support, and supervise local clinics where the staff could manage diarrhea, pneumonia, and malaria before the children became terminally ill. It would save many more lives than giving intravenous fluids to dying children in the hospital.
Hans in Nacala with colleague Anders Molin
* * *
The child mortality rate in the town turned out to be about 20 percent, not the 10 percent I had originally estimated. We expected it to be higher in the countryside where three-quarters of the region’s population lived. I should be trying to prevent more than three thousand child deaths each year, of which only fifty-two were happening in the hospital. It would have been seriously unethical to spend more resources on the hospital before the majority of the population could access some basic form of healthcare.
“Basic healthcare for all” had been a World Health Organization policy since 1978 and the WHO had for decades been prioritizing vaccinations and basic-care facilities for as many children as possible in as many countries as possible. I was lucky to be working in Mozambique, a country that had begun to implement these policies immediately after gaining independence. During my years in Mozambique, many villages were invited to send a representative to the city for a brief period of education. The focus was on creating small healthcare units in all areas, within walking distance for mothers with babies and very young children. They would offer vaccinations and treatments for the main diseases that killed young children.
Were we right to take our lead from the terrible facts of child mortality, rather than to be guided by what was thought to be ethically correct when managing hospital care? Yes. When I was working in Mozambique, child mortality was estimated to be at around 26 percent and, now, thirty-five years later, it is down to 8 percent. It took sixty years in Sweden, from 1860 to 1920, to reduce child mortality from 26 to 8 percent.
During those thirty-five years, Mozambique endured a decade of bloody civil war and coped with a very serious epidemic of HIV. Despite this, its child mortality fell almost twice as fast as Sweden’s had almost one hundred years earlier. This also holds true if you compare Europe and Africa overall. Africa is catching up with Europe in matters related to child health, and it is due to accepting evidence-based policies and investment targets.
It can be difficult to persuade oneself to prioritize thinking rather than feeling, but it can be done through careful tallying and thinking clearly about the data.
There was one thing that I still had not grasped through looking at the numbers, though: the true depth of extreme poverty. I understood this first when prompted by the most powerful of feelings—fear.
* * *
A whole series of tragic and dramatic events took place during our life in Nacala but we also experienced many good things together. Anders Molin’s arrival meant that I could relax when he was on duty and I enjoyed wonderful family Sundays on the beach. As I was no longer on call every night, I could also spend some evenings with the children and sleep soundly at night.
We did the hardest work of our lives in Nacala, but, in the middle of all that, we were a happy family. We grew papaya and kept ducks in the garden, a dry-as-dust patch of sandy soil. Despite the challenges, our health was fine. One magic night, Agneta hugged me and whispered in my ear: “I want another baby.” To us, the children were our source of joy and meaning in life. It was how we wanted it to be for many years to come. To me, Agneta’s wish sprung from love but also from a shared vi
sion of life beyond my cancer.
She became pregnant faster than we ever imagined and at first her pregnancy progressed well. Together, we followed the growth of her belly by measuring it every Saturday, the day a midwife came to make her own checks. Then, one Saturday toward the end of 1980, we realized that there had been no growth during the past week. There was no change the following week either. We had to take this warning seriously.
During the next week, we had to make a critical decision: would we risk a delivery in Mozambique? No.
In January 1981, Agneta and the children boarded the plane from Maputo to Sweden and I returned alone to Nacala. Our plan was that a month later, just after the birth, I would fly back to be with them.
The day after Agneta and the children had left, there was an outbreak of cholera in our hospital’s catchment area. Cholera is fast-moving. Once the diarrhea has set in, a patient can die within a few hours. I immediately gathered a team of three health staff with the necessary equipment and left Nacala. As I had been taught to do, we settled temporarily in the center of the outbreak. Our basic intensive care unit stayed in place for two weeks to do battle with the epidemic in the most distant villages.
One evening, I was stopped on the road by a man who was carrying his unconscious son. The boy was a cholera victim, his sister had already died of the disease and their father knew that he probably would soon lose his second child. At some point after the boy’s diarrhea had begun, his father had heard the distant engine sound of our car. He was sure we would come back by the same road and, even though their home was far up in the hills, he had set out for the road, carrying his boy on his back. When he put the child down on the ground, I saw by the glow of the headlights how quickly the sand became wet. The child was losing far too much fluid and must be taken to the unit quickly.
