How I Learned to Understand the World

by Hans Rosling

  I was becoming more and more certain that we were not dealing with an infectious disease. One evening, I was sitting at the tin desk in my office. The last nurses had returned and made their reports for the day, and the data had been added to the maps and graphs on the wall. We had combed the records of the town’s healthcare centers but found nothing.

  I gazed at the board-covered wall and suddenly thought: Hans—it’s time to stop searching. You have conclusive proof right here. What you see in front of you is incompatible with a disease that spreads from one person to the next. The answer is staring you in the face. The areas with disease outbreaks coincided with the areas stricken by drought. In all probability, the paralysis was caused by malnutrition and some related poison, a combination unique to the people in the outbreak areas.

  For me personally, this conclusion mattered greatly. It meant that I ran no risk of becoming paralyzed myself. Emotionally, it felt liberating. That evening, sitting in front of my maps, I wrote a letter to Agneta. I had kept her informed throughout, so I just described how I had arrived at my conclusion. I was quite certain. Once I have thought through an issue properly and worked out my response, I trust it. Now, Agneta and the children could come back home without running the risk of infection.

  When my family arrived, we hugged each other for a long time. We slept and ate together, without my harboring the slightest doubt about whether it had been right to bring them home. Work became easier now that I was together with my family once more and able to discuss the investigation with both Agneta and Anders.

  * * *

  We had established that the paralysis was not due to transmission from one human to another but we had still not isolated its cause. This required detective work and I was utterly dedicated to my task. I focused on it to the exclusion of everything else but these were calm, orderly working days. The hospital was run by Anders together with the doctors and nurses we had borrowed from the provincial hospital in Nampula. Systematic, monotonous and madly exciting. No stress. I had time to think. It was fascinating to fill in the data maps and see the overall picture growing clearer and clearer.

  Our number one suspect was the drought. The outbreak coincided in time and place with the summer period of no rainfall. As well as analyzing the figures, we traveled to the countryside to find out what people had been eating and how their food intake had differed from previous years.

  Their main crop and chief source of food was the bitter type of cassava root. The bitter taste is due to naturally high levels of substances that can form cyanides—just as in bitter almonds. The poison is usually deactivated if the roots are left in the sun for several weeks to dry out slowly. They are then ground into flour to make a thick porridge. The women’s knowledge about the detoxification process serves as an invisible lock on the fields and keeps out the three most common kinds of thief—monkeys, wild boar, and hungry men.

  It didn’t take me long to realize how pointless it was to ask starving people to fill in questionnaires about their eating habits. I had quickly turned into an anthropologist and Agneta helped me in my studies. Gaining the trust of a handful of families and staying with each of them in turn, accompanied by a respectful and kind interpreter, is the most effective way to gain an understanding of personal habits and beliefs.

  We heard the same story again and again: “We know the roots are bitter, and in the dry period they became more bitter still. Hoping for rain, we left them in the ground as long as possible to give them time to grow bigger. My husband went to the town to try to get a job and buy some food but then the day came when we had nothing to eat. I pulled up a few cassavas and tried to get rid of the poison by a quick method. I would bash the fresh root to little bits, leave them to dry in the sun for half a day, and then crush them some more. On the second day, I would make flour and prepare some porridge for the children.”

  Through these conversations, a way of life emerged that none of the patients had mentioned in thousands of medical examinations. We now had insights into the reality of subsistence farming that I would never have fully grasped even after decades of hospital-based work.

  We formed trusting relationships with the women because they could offer us the explanations we needed. We needed to know: “What would you do if you had no food at home and no money, and no crops to pull from the fields?”

  “I would go to a family that I knew needed help with harvesting. I would sit in the shade of a tree and look down on the ground. They would know what it meant so they would come and ask me if I wanted to help them dig up cassava roots.”

  One of the women explained that this was a countryside tradition, a kind of social-welfare system rooted in the local culture. The person seeking work would be shown a part of the field where she could harvest all the cassava roots. Her next job was to carry them to the yard in front of the house, peel the roots, and then top and tail them. The middle part had to be halved lengthwise and left in the sun to dry.

  Traditionally, she was paid a wage in kind: she could keep the cutoff ends of each root, though if the bits she cut off were too large, she would become known as a “big-end cutter.”

  “I would never do that. That’s a bad name, it shames you. But this year, the difficulty was that hardly any families had enough cassava to let me help them with the harvest.”

  As I listened to the woman describing this age-old system of assuring food for all, and how it had collapsed, I began to wonder if there could be other factors behind the triggering of the epidemic. But, as so often, it wasn’t thinking that led to insights but random observations.

  Through my office window back in Nacala, I could see the motorbike drivers arriving back from their day trips to the drought-stricken areas with not only their nurse passengers but also sacks tied to the backs of the bikes. When I asked what was in the sacks, their answers were evasive. Then a nurse told me: the sacks contained sun-dried cassava roots.

  “What? You come back from places where there is serious lack of food and the drivers have bought up the cassava from the villages? How can that be?” I demanded.

  This was obviously a sensitive matter, but one of the nurses stood up for the drivers.

  “They are paying good prices. You can’t imagine how expensive cassava flour is in town nowadays. It’s because of all these months of drought.”

  This was an example of centralized planning at its worst. The socialist government had forbidden private trade in food but had failed to satisfy the needs of the people from centrally held stocks. A black market for cassava had grown up and was swallowing both official and unofficial supplies.

  We drove out to a village that had been badly hit by the paralysis and tried to find out if the families were selling cassava on the black market rather than helping their neighbors.

  This was a delicate matter because such trade was forbidden. After spending the day with some of the families as they worked in the fields, we had built up good relationships. But every time I tried to shift the talk to cassava sales, they avoided the subject. Finally, we had to leave. As we walked to the car, the male head of one of the households took my hand and pulled me aside. This had happened many times before—many crucial pieces of information came my way just as I was about to leave, sometimes when we hugged good-bye.

  The man looked me in the eye and said: “We understand what it is you want to know, Doctor. You know as much as we can tell you. It’s a family secret if we have sold cassava or not. We will never speak of this with anyone.”

  What he said revealed that they had sold every root they could lay their hands on. None of them would ever admit it, for two reasons: it would be a breach of the Marxist government’s doctrines and, worse, it would be a breach of the rules of local culture.

  Finally, the rains came and there were no new cases of paralysis. We carefully wrote up the data and our preliminary conclusion: that the nerve damage had been the result of a combination of undernourishment and an unusually high intake of a naturally occurring tox
in. The underlying causes were the drought and probably a lack of alternative ways of getting food during periods of scarcity.

  We presented our five-page report to Dr. Pascoal Mocumbi, the minister of health. Wanting to understand better, he quizzed us. Then he thanked us for our work and presented us with a signed copy of a book about Mozambique.

  There is something deceptive about the battle against epidemics. You are duly praised for the immediate, dramatic actions. But it is building and managing a better community that saves the greatest number of lives; the steady, unrelenting work that goes into this rarely receives the attention it deserves.

  This epidemic had taken me into local villages and households, closer to individuals. Through them, I accumulated insights into people’s ways of life and could observe with my own eyes how a system could break down and stop functioning. Later, I would study such collapsed systems in order to better understand the various components that must be functional if a society is to haul itself out of extreme poverty.

  * * *

  All this happened as our contract in Nacala was reaching its end. We had undertaken to work there for two years and these years were nearly up. We had endured, and we had completed our tasks.

  By then, I was exhausted and the rest of the family was very tired too. Still, we had not hit a wall and given up—we had broken through it. I had survived cancer; our newborn child had died; we had fought an epidemic; we had gained a hard-won intellectual grasp of how hard it is to develop a country and how long it takes. At that point, despite all the questions the epidemic had raised and left still unanswered, it did not occur to me that I would return home only to spend the next twenty years researching just these questions.

  The one thought dominating all our minds was that we were going home to rest.

  As planned, we had packed up our work and our home by the end of October 1981. We were happy, despite the challenges we’d faced, and tightly united as a family. But if someone had asked me to stay for one more week, I would have burst into tears.

  We had promised Anna and Ola—now aged seven and five—a little holiday before going home. We realized there would be no time to rest in Mozambique and decided to take a break on our journey home to Sweden, which took us via Geneva. We had to go there anyway to hand in blood and urine samples from our investigation into the epidemic for analysis at the WHO’s toxicology department. Mozambique lacked the necessary technical resources.

  We rented a car in Geneva and marveled at the experience of driving such a clean, perfectly functioning vehicle. There were child seats in the back and Agneta sat next to me in the passenger seat. We looked at each other. I turned the key and suddenly classical music streamed from the loudspeaker. The sensation was dizzying. We had landed on “another planet” and I could barely take it all in.

  Our samples were in a large freezer box in the back of our spotlessly clean rental car. They were kept cold with dry ice but we knew the CO2 would soon evaporate, so we were keen to hand them over. It brought an enormous sense of relief to transfer responsibility by leaving the samples in a fridge in the basement. We left the massive WHO building feeling content.

  What to do next? We turned to our children and it struck us how tattered they looked. Everyone in Geneva was nicely dressed, except us. Our children looked as though they’d been dressed in bits and pieces from a flea market, even though we had tried to dress them up for the journey.

  So, we went to a big shop to buy clothes for the children. That same evening, they wrote their lists of Christmas wishes to hand over to their grandparents when they came to meet us at Stockholm Arlanda Airport.

  * * *

  Readjusting was a quick process, and the children made a real effort at it. We bought them satchels for school. Everyone got an appointment with the dentist. Agneta returned to her job at the maternity unit and I to mine in the medical wards. We really were very shocked to see how different everything was in Sweden. We had new winter tires fitted on our shabby little blue car and we booked a slot with a photographer for Christmas card photos. We immersed ourselves back into Swedish family life.

  But after a while, leftover tasks from Mozambique began to pop up in our thoughts. Agneta had promised to edit a booklet with instructions for maternal healthcare and family planning. The text was ready and we had it printed and shipped to Maputo.

  I had received a letter from Maputo telling me that so far, no analyses had been made on the samples I had left in Geneva. My friend and colleague Anders Molin, who was also back in Sweden, said he was worried that the paralysis epidemic would strike again in the next dry season. It had been easy to adjust to life at home but it also proved impossible for me to forget the experiences from Nacala and the responsibilities I still bore.

  Was the form of paralysis I had observed truly a condition new to medical science?

  One morning in spring 1982 I was given a push to carry on with this line of research: a seriously mobility-impaired patient came to see me at my clinic in Hudiksvall. Her entrance into my office stunned me so completely I forgot to greet her: she walked with crutches, her knees turning inward and her wrists twitching at every step. It was exactly the same spastic pattern that I had been investigating a few months earlier in Mozambique. She told me that it was an inherited disease. She had been an adult when the first signs appeared and her difficulties had grown worse with time. She wanted to know if there was a way of stopping further deterioration. She had been seen by a specialist a few years earlier but had been offered no treatment.

  “Has there been any new research that could help me?” she asked.

  After examining her, I promised that I would search for a way of halting the progress of her condition but that it would take a couple of weeks. I would contact her and arrange another appointment.

  Later that day, I knocked on the head consultant’s door eager to talk to him. Pontus Wiklund knew his town very well and would be able to identify the family with this heritable health problem. He listened and looked curious.

  “You see,” I said, “it looks precisely like the nervous deficit we saw in the paralysis cases I investigated in Mozambique. If it’s inherited, I must read all the literature there is. Any more information would help us arrive at a better understanding of the underlying cause.”

  My wise boss smiled and said he had always thought I would end up in research. It was fortuitous that I had presented my ideas just this week: health service research funding for doctors was in the pipeline and he had been feeling ashamed that no one from his department had put forward an application. I applied and was duly given a grant to study the links between the epidemic of lower limb paralysis in Mozambique and the cases of similar, inherited paralysis in Hudiksvall. All this brought on a crisis of identity. I was a reluctant researcher.

  I had always suspected there was something phony about research and didn’t much care for it. The terminology sounded pretentious and the format of what you said seemed to matter more than the content. I was irritated by the stagey, vaguely pompous ceremony surrounding things like the presentation of degrees. Generally, I was skeptical about the whole elaborate system and found it hard to shift out of my underdog perspective. All these attitudes I would later dismiss as silly. For one thing, academic events are important for networking with colleagues and other contacts.

  I sought advice from senior academics: what should I do next? Their suggestions were straightforward: go on research leave for a couple of months and read everything you can find about the conditions you are interested in. Apply for funding to follow up your earlier work on-site in Mozambique. Meanwhile, try to land a post at Uppsala University Hospital so that you become a member of an academic organization. And register your doctorate now: you need to learn more about how to do research.

  I wrote up a plan for my doctoral thesis and it was accepted. It was my good fortune that my supervisor was Bo Sörbo. He was a tall, kind man who had spent a large part of his life on toxicology research, driven only
by his own curiosity and not by a taste for titles and status. He taught me what science is really about.

  Bo Sörbo had an absolutely decisive influence on my career. Apart from being a brilliant chemist, he was also an easygoing person, a family man and a football enthusiast. At the outset, I worried about having to write an entire doctoral thesis, but Bo told me to relax.

  “Never mind the academic formalities, just get on with the work. The actual research is going to take many, many years,” he said.

  However, he was quick enough when it came to getting results. Two days after I had delivered the samples from the Mozambican patients to him he was on the phone to me, speaking excitedly.

  “You were right! The people who were sampled had been ingesting something that gets broken down into cyanide in the body. You must apply for more money to go back and conduct a follow-up study!”

  Over the next two years, I went back to Mozambique for several short periods of fieldwork, bringing home samples to be analyzed in Bo Sörbo’s laboratory. I read as many research papers as I could find and wrote five papers based on my own work.

  Meanwhile, my family grew, with the wonderful addition of our son Magnus, who was born in 1984. After another spell of parental leave, I compiled my research results into a thesis, which I presented in 1986.

  My results had come out in support of my preliminary conclusions from 1981. The drought had killed off all other cultivated plants except for cassava, and cassava production had been low compared to normal levels. The food shortages made people resort to leaving the roots to dry in the sun for a shorter time than usual, which meant that they contained far more than usual of the substances that could be metabolized into cyanide. I wrote about the new condition using technical, descriptive terms but discovered that it already had a name. In the 1930s, an Italian doctor working in the Congo had written a report on an identical outbreak of paralysis. The local people called it konzo, which meant “bound legs” in their language.