How I Learned to Understand the World

by Hans Rosling

  We did not want the cholera infection to soak into the car seat and put him on the floor of the car instead. He was unconscious, his pulse was too faint to detect and there was no chance of making him drink. He was half an hour from death.

  The father was completely calm and collected, and entirely focused on his child. Knowing that we had cured other people with cholera, and that his son’s fading life depended on me, he was helpful and intensely alert.

  It was dark when we arrived at our base unit. We parked the car but kept the headlights on. I asked the driver to shut down the engine so I could hear the boy’s breathing. The darkness and silence were broken only by the noise of his breathing and the nighttime sounds of the forest around us—mostly from frogs and geckoes. The father sat still, the nurse stood behind me. Everyone was silent.

  I searched for a pulse somewhere. Was he dead already?

  Finally, I picked up a faint arterial beat in the groin. I had to get a needle into the big vein lying next to the artery. I sensed the small snap of the needle piercing the wall of the vein. With the needle in place, I could then hook the boy up to an intravenous drip. We had fluid-replacement bags and flow monitors—small chambers showing the flow rate for the drip. The flow began. I crouched in front of the boy with my fingers on his pulse, staring at the monitor, and asked the nurse to let the fluid go in at top speed.

  “Hold his legs still,” I instructed the father.

  He took his son’s legs in an iron grip to stop him from moving and damaging the vessel with the needle in it. My body was going stiff from crouching. We were very quiet. The fluid flowed and flowed.

  Minutes passed. Five minutes. Ten. Nothing happened. Eleven. Twelve. The boy’s eyelids twitched, his eyes opened. He lifted his head. He was waking up.

  Still, his father kept himself under control. I heard him behind me, the deep breaths he took as he watched the nurse going down on his haunches to control the boy’s first movements. When we had delivered a liter of saline–glucose solution into the boy’s blood circulation, I removed the needle and put a plaster over the entry hole in the groin. Then I showed the father how to feed the boy and give him fluids by mouth. He observed me intently while all the time whispering gently to his son.

  I thanked the father for his help. He was at a loss and could not think of what to say.

  The following morning I went to see them. The boy was better.

  Sometimes, our chances of stopping an epidemic depended on curing single cases. My colleague Mama Lucia used to exclaim: “Thank the Lord for cholera.” She meant: It makes it so obvious to onlookers that healthcare staff can save lives. Every individual case cured increases trust in doctors and nurses, and so makes public health measures of all kinds more accepted. In order to be believed in by a population you have to create a situation of trust between yourself and the patient’s relatives. Returning someone’s dying loved one to life after an attack of cholera is an obvious way to instill a sense of respect.

  This became very clear to me during a day fighting cholera in another village in a distant rural area toward the end of the epidemic. That day I got a real insight into what extreme poverty means.

  We arrived at sunset. Our small, white jeep attracted instant attention. Before we could find somewhere to park, a flock of teenage boys started running alongside us. When I stepped outside, I faced a growing number of people of all ages with their curious faces fixed on us.

  The male nurse in our team spoke the local language, Makua. He was about to introduce us when the crowd started to mumble and I picked up two words in Portuguese: Doctor Comprido. It was my nickname, based on anatomy: I was the taller of the two Nacala doctors and my colleague Anders had a beard, so we were known respectively as Doctor Tall and Doctor Beard. But it overwhelmed me to find that they had heard of me in this place, one of the district’s most remote villages and one I had never visited. I couldn’t remember if I had ever treated a patient from here in the hospital. The village was not even within the area covered by our mobile vaccination team.

  Instead of introducing us properly, our nurse had to translate my surprised question: “How do you know who I am? I have never been here before.”

  A man, whose manner indicated that he was the community leader, stepped forward and replied calmly: “You are very well known and respected here. Everyone in this village knows of the doctor in Nacala.”

  Of course I felt flattered but I was still doubtful.

  “I cannot remember treating anyone from here.”

  The leader knew more than I did.

  “Yes, you did. Two months ago, a woman who could not give birth to her child was carried by her relatives to the hospital. You treated her there. Her family and the whole village are all very grateful for what you did for her. That is why you are so well liked here.”

  No young doctor could fail to be pleased by hearing something like this. I stayed by the jeep, asking about this woman: had her delivery been complicated? Once my question had been translated, the group confirmed by nodding and mumbling seriously if incomprehensibly that, yes, the birth had been very difficult.

  After a week of hard and often very frustrating work dealing with cholera, I had no problem with seeing myself as a local celebrity and skilled obstetrician. I looked for a final confirmation from the crowd, which by then had grown to about fifty people. If the birth had been so difficult, were they really satisfied with the care I had given this woman in the hospital? Translation, then smiles, nods and positive mumbling. But my next question, “May I meet this woman?” was followed by a surprising and drawn-out silence. I took this to mean that something had been lost in translation, but the village elder broke the silence with his brief reply:

  “No, meeting her is not possible. She died when you tried to get her baby out of her belly.” I had never been so astonished and couldn’t believe what I was hearing. I repeated the question. The reply, though longer, was in essence the same. When her labor had begun, the baby’s arm had come out first., Then the baby had got stuck. The traditional midwives had tried everything they knew about how to get babies out. They had even pulled at the arm until the baby’s skin nearly peeled off. At this stage, the woman’s husband and her brother decided she must get to hospital, but the village had no means of transport—not even a bicycle.

  They made a stretcher from a length of cloth and two long poles, lifted her onto it and carried her twenty kilometers through the forest down to the coastal dirt road, where they eventually managed to stop a passing truck. The stretcher went on the back of the truck and, as dawn broke, they arrived at the hospital.

  Doctor Tall had spoken to them on arrival and told them that they had been right: the woman’s life was at risk. He had tried to remove the baby, who had died by then, by cutting its body into bits. Then the mother had started to bleed heavily and died. This is why you cannot meet her, they told me.

  This terrible story was told to me in translation, sentence by sentence. And now I remembered. I will never forget my pointless efforts to save the life of the febrile, dehydrated woman. It had been another case requiring the extraction of a dismembered baby but this time it was too late. The mother was extremely frail, and already suffering from advanced sepsis after her prolonged labor. Her uterus ruptured from my attempts to extract the dead baby and the hemorrhage killed her almost instantly. It had been unavoidable but I had felt as guilty then as I did now, facing her family and neighbors.

  The village headman ended his explanation by expressing again the thanks of the village and how pleased they all were that I had come to be with them. I was by then long past trying to understand why, exactly. My confused brain could only think of one explanation for their satisfaction: they would at last have an opportunity to kill me. I have never gone from pure pride to deepest terror in such a short time. I fell silent and must have looked scared to death.

  No one moved. They just kept smiling. I considered asking the driver to leap into the car and drive us away at t
op speed. But, by then, the car was surrounded on all sides by villagers. Instead, I leaned closer to the bilingual nurse and asked him:

  “Do you understand why they say they are so grateful, when the woman died?”

  “No, I don’t. It’s crazy. Shall I ask them?”

  I didn’t reply, but he put the question to them all the same. People began talking across each other until their leader once more started to speak and they fell silent. His answer was slow and very clearly enunciated but I understood nothing and had to wait for the translation.

  “Oh, doctor, we all understand that the situation was very grave and that saving her life was almost impossible. We still are very grateful for everything you did for her. The entire village is grateful because of how you dealt with it, and for that you will be remembered by us.”

  Now my confusion was complete. I whispered something like “But what did I do?”

  The village elder replied in a declamatory voice that was reinforced by the murmured approval of the crowd. To this day, I remember his words as they were translated, sentence by sentence.

  “What you did for this woman was very important for her and for her family. It was beyond any expectations of people here, in our remote and extremely poor village. We would never have believed that an important person like a doctor in the big town would do what you did for one of us—a poor woman. After her death, you personally expressed your sorrow to the family. Then, you walked out into the yard in front of the hospital and spoke to the driver of the vaccination van. It was just about to leave but you ordered the driver to wait, and to drive the dead woman’s body back home for the burial. You gave the woman’s husband a clean sheet so that he could wrap up his wife’s body. And you gave him a smaller sheet for the parts of the dead baby. The husband and his brother came home in the van, too. It meant that they all returned home in the afternoon so that, by the evening, the whole family and all the villagers could together give the dead woman and child a dignified funeral. You always remember when you are shown respect during a difficult time. Neither you nor the driver demanded any payment whatsoever. I can tell you now, in all honesty, that her husband and brother between them did not have the money to pay for the transport of their dead. If it had not been for Doctor Tall, they would have been forced to carry their dead all day and night.”

  Of all the suffering I have witnessed, this particular experience stands out as the most powerful and tangible example of extreme poverty: people are robbed of the most fundamental elements of dignity by sheer lack of money.

  A very important aspect of the sad story had however not emerged: I was praised by the villagers for someone else’s decisions. Yes, I did have the decency to see the husband and brother after the woman’s death and express my deep sadness. But it had not occurred to me that getting the bodies home for burial would be a nearly insurmountable challenge.

  After my brief talk with the two bereaved men, someone took hold of my arm and pulled me aside. As so many times before, Mama Rosa wanted a word. She said, quietly and very seriously: “Don’t you know that these two men carried her all the way here? It took them the whole night and they have not eaten or slept. Don’t you realize that they have no money?”

  I hadn’t thought of any of this.

  “Now, you ought to start thinking about how they are going to get her dead body home for burial in their distant village.” Speechless, I listened to her instructions.

  “Go out and stop the vaccination van before it leaves. Tell the driver that he is to take the two men home and also the dead woman and her child. If you don’t help them with this, a decade will pass before any other woman from that village seeks help with a difficult pregnancy. Hurry! I can see the van is packed and ready to go.”

  As has happened so many times in my life, I was given the credit for what other people had done. As I stood there, facing the villagers, I reflected on the boundless reach of Mama Rosa’s wisdom.

  She had offered them their first contact with a life beyond poverty. For the first time, they had the opportunity to see what healthcare and ambulance services could mean as part of their ordinary lives.

  * * *

  When we had finally controlled the cholera outbreak, I returned to work in Nacala. Soon, the day arrived for me to travel back to Sweden and my family. It was impossible to make international calls from our house in Nacala, and even phoning the capital from the telephone office in the town center was a tricky enterprise. It was only when I disembarked in Maputo that I received news from home. The news was very shocking: our daughter had died a few hours after being born. She had a congenital malformation. Agneta was now in hospital with life-threatening complications following an emergency caesarean.

  I boarded a flight to Sweden the following day. At the airport in Paris, I was finally able to speak to Agneta, and later the same day I was sitting by her hospital bed in Uppsala. In the middle of our tragedy and my overwhelming emotions, I remember how impressed I was by the cleanliness of everything in the ward. How the stainless steel tubing of her bed shone. There were no cracks in the floor, the sheets were not torn or patched. The air didn’t smell bad. One of the powerful feelings that gripped me as I hugged and kissed Agneta, and wept with her, was my awareness of how lucky we were. Our baby daughter had died but Agneta was alive. If she had given birth in Mozambique, she would have died from the complications that followed her delivery. We could afford to travel and had been born with the correct passports, which gave us the right and privilege to claim treatment from the best healthcare system in the world.

  The following day, Agneta was allowed to get up. We drove to the mortuary behind the hospital and spent an hour there with our departed daughter. Then she was cremated and we took her ashes to be buried in the family plot in a cemetery on the edge of the city. Agneta and I went alone, feeling closer to each other than ever. In the hospital, we had been distant from our lives in Mozambique, but standing there in front of our daughter’s grave, we felt deeply for the many Mozambican parents who had also lost very young children and whose grief was as profound as ours.

  When we returned to Nacala, we noticed a difference in the kind of support we were given. In Sweden, young couples whose children had died were rare. Many of the people around us there seemed to have no grasp of how to approach or comfort us. But in Mozambique, most of our neighbors and colleagues had known similar losses and had traditional ways to offer consolation. We were welcomed back to our jobs in Nacala with both gratitude and great compassion.

  4

  From Medical Practice to Research

  “To: The doctor in Nacala. Come here at once. Over last few days, 30 women and children admitted with paralyzed legs. Query: Polio? Sister Lucia. Health center in Cava.”

  On an August morning in 1981, I received this note. It had been scribbled on the back of an old cinema ticket. Sister Lucia worked in a small Catholic mission, based in the health center in a remote place called Cava. During my work in Mozambique I had so far only felt the need to apply the basic principles and practices of existing medical knowledge. Sister Lucia’s words would change me.

  She was a very highly regarded Italian nurse and nun, who for more than twenty years had been working in Cava together with two other nuns. Sister Lucia was well known in the entire region around Cava, admired by the women and respected by the men. Among other things, she was famed for riding a 250cc motorbike and for never asking for help. So I felt her concern must have been prompted by something extraordinary.

  The following day, we packed the jeep full of staff, clinical textbooks and equipment. After a day of driving along sandy roads, we arrived at sunset. Sister Lucia stepped outside her office to welcome us, and I noticed straightaway that the Mozambican staff addressed her as “Mama Lucia.”

  I had assumed that I would start examining patients immediately. Mama Lucia wouldn’t hear of it. She took charge, saying that I wouldn’t see anyone tonight because it was time to go to sleep. She took us to the si
mple but clean guestrooms. Mine had a window facing the health center and in the moonlight I could make out the paralyzed women and children sleeping on straw mats spread out on the veranda.

  That night, I dreamed of hundreds of paralyzed people.

  A knock on the door woke me. We prayed, ate breakfast, and Mama Lucia told us that at exactly 8 a.m. we were to start meeting the patients.

  They all told us the same story: suddenly, both their legs had become useless. No pain, no fever and no other symptoms. All of them had fallen ill during the last few weeks, most of them just this past week. They still had sensation in their legs—at least, they could feel me touching different points. Some of them could stand if there was something to lean on but they soon developed spasticity (contraction and spasms) in both legs. This was definitely not polio. But if not polio, then what was it? I could not make my observations fit any disease described in my hefty neurology textbook.

  While I continued with my investigations, more afflicted people arrived from villages in the neighborhood. This was feeling more and more strange. Then, an idea struck me: it could be a virus. An infection. That thought triggered another and yet another until thoughts washed over me like waves and I became fearful. Might not I, too, become infected? Or what if I had already caught it—whatever it was?

  Fear took my mind hostage. Everything else was put on hold. I tried to check the patients’ reflexes but could not concentrate. When I tried to write down what I had observed I had already forgotten and had to start again.

  As the afternoon passed, questions crowded into my mind. Why am I stuck here? This wasn’t part of the contract. To deal with an emergency of this magnitude, one needs quite different kit from what’s available to us. Is it a completely new type of epidemic? Surely there’s somebody somewhere who is better equipped to deal with this than me? Somebody who could be flown in?