How I Learned to Understand the World

by Hans Rosling

  * * *

  By now, you will have an idea of who I was in 1986: a proud young father of three children, and a qualified medical man with an academic doctorate. I had not only described a disease but could also claim that my research had identified a possible cause for it. I remember being both baffled and miffed when other university scientists seemed rather less impressed than I had anticipated. I was probably not especially easy to get along with at the time. Anyway, I had been focused on work and now it was time to take a long summer break with my family.

  We had decided to rent a house for the summer on an island in the Stockholm archipelago. It was the very best kind of family summer holiday. We were free. Agneta had just completed two years of the medical curriculum. I had been cancer-free for eight years and began to feel that I must be cured. My professional future looked promising and full of new opportunities.

  On my first day back at the university after the holiday, I received a shock as deeply felt as any unpleasant surprise can be by a young scientist who thinks too well of himself. This was the final sentence in a new paper on konzo and it spurred me on to continue with my study of the illness for another fifteen years:

  Our observations indicate that the cause is an infection and therefore does not support an explanation based on cyanide poisoning due to substances present in local foods, a hypothesis put forward to account for an outbreak of a very similar disease in Mozambique.

  With mixed feelings of anger, curiosity, and duty, I settled down at once to study the article. I read it several times, from beginning to end. It was written by scientists from Belgium and the Democratic Republic of the Congo, or Zaire, as it was known then, and published in a leading neurological journal.

  Their paper stated that they had come to three important conclusions. The first was that konzo outbreaks still occurred in the Congolese region of Bandundu. The second was that konzo and the condition I had investigated in Mozambique were the same disease. So far, so acceptable for the tense reader. Their third major finding upset me, though: their statement that konzo was, in all probability, caused by a viral infection. They went on to suggest that I had been wrong to conclude that the cause was a combination of malnutrition and ingestion of cyanide precursors present in cassava.

  In my view, their interviews with families had been handled in too cursory a way. However, with every new read-through, I grew steadily more humble. I slowly realized that my wise supervisor had been right to say that a doctoral thesis was simply a driver’s license that allowed the graduate to gain more experience in research. I also realized that I would not be able to counter their evidence from where I currently sat. I was going to have to investigate the situation in remote parts of the Bandundu region. Over the following days, I sought out my academic mentors and listened to their advice about how to best handle what I called “the attack from Belgium.”

  My distinguished advisors offered their opinions clearly. First, nothing would be gained by starting an argument. The conclusion that we were dealing with an infectious disease was reasonable. However they agreed with my reasoning that my critics’ interviews with the afflicted families in Congo about their cassava consumption had been quite superficial. Also, the researchers had not analyzed any blood samples.

  “Hans, you’ve got to go to the Congo and interview people properly,” Bo Sörbo said, nearly shouting. “And bring samples back for analysis!”

  He was wildly excited by the notion that I would be bringing blood samples from remote parts of Africa back to his lab in Linköping.

  “But I’ve no money to do it,” I replied wearily.

  “Then you must apply for new grants! It’s in your favor that somebody has published a paper saying that you’re wrong. It will increase your chances of getting the funding you need.”

  I understood well enough. Bo Sörbo was right. I had to go to the Congo.

  * * *

  The preparations took two years. I had to write official letters to ministers and my university for permissions to do the studies and I had to ship equipment to the capital, Kinshasa (first it was mistakenly sent to Kingston, Jamaica and had to be dispatched back across the Atlantic). More importantly, I had to establish a network of contacts in the region’s villages.

  I was assisted by my local colleague Banea Mayamba, a young Congolese doctor and postgraduate student, who was also the head of the local authority dealing with food and nutrition. He claimed that as he came from a tropical region he was incapable of orderly thought in temperatures below 75 degrees and had arranged it so that it was always at least 82.4 degrees in his office.

  There was a tradition at our university that was supposed to make the postgraduate students feel more confident that they were making progress: they were encouraged to nail their thesis to the wall. Actually, the idea was to hammer a nail into the wall, punch a hole in the corner of their “book,” thread a loop of string through it and then hang it up. Seeing it there on the wall was supposed to raise the self-belief of students scared to death by the thought of the public viva examination. Banea had never learned how to hammer a nail into anything so I took a board into work and made him practice in the secretary’s office on the day his thesis came back from the printers.

  * * *

  Banea and I built a chain of trusted contacts, first between Uppsala in Sweden and Kinshasa in the Congo, then between Kinshasa and the small town of Masi-Manimba, and from there to the clinics and the nuns in the Catholic mission in Lumbi. Finally, and crucially, we had to talk to the village elders who, in turn, would try to convince local people to take part in our study. We needed everyone to understand exactly what we proposed to do, and why, and to give their consent to being involved. Previous studies had shown me the hard way that nothing could be done if people considered you to be a complete stranger.

  I brought a postgraduate student with me from Sweden, a man called Thorkild Tylleskär. He had entered my life a few years earlier, during a lecture I gave on the medical course in Uppsala, during the so-called disaster medicine week. Thorkild asked detailed questions about cassava cultivation, with an intensity that ignored any conventions of politeness. He spoke eagerly, leaning forward as if to get closer to the answers, and smiling all the time. He was curious, argumentative, and uninhibited. I would later discover he was also possessed of a special capacity for absorbing details and very hardworking.

  Thorkild had taken a break from his medical studies to take a course in African languages at the Sorbonne. During an earlier visit to northern Congo he had learned from the Baptist Church missionaries there that they did not address the local people in their local language, Sakata. As Thorkild and his wife planned to work as missionaries, after the course they had headed off to a Congolese village where they lived for a year while he charted the structure of Sakata and finally wrote it up as a master’s thesis in African linguistics. After all that, he had returned to his medical studies. Now, he was coming with me to investigate konzo in one of the agricultural areas of the Congo.

  On board a boat in the Congo

  Our first night was spent in the capital. Before leaving for the countryside, I was nervous and could not sleep. After two years of preparation, we could not afford any failures. I turned on the light several times to add another item to my to-do list and run through again the details of our plans for each day, though I was well aware that most of our plans would be subject to abrupt changes due to unforeseen circumstances.

  When I finally accepted that I could do no more that night to prevent the project from going wrong, I tried to sleep but was assailed by new worries. What about my own safety? The chief danger was car accidents; driving at night was out of the question. What about illnesses? I had taken my malaria tablets and had all the necessary vaccinations. My personal medical kit included the most effective antibiotics available. But there were risks that medical precautions could not deal with, in particular robberies and other forms of violence. What if we were met with aggression? I had experi
ence in approaching people respectfully in remote farming areas, being polite and taking the time to listen. Talking with both leaders and ordinary people was essential before trying to do anything at all—it was a rule I intended to follow. Permission from the authorities was a formality but what really mattered was that every local leader and every member of the studied population knew our reasons for being there and agreed to our conditions.

  Before I finally fell asleep, I thought about my wife and my children. Earlier that evening, I had been on the phone to Agneta but, from tomorrow, we would not be able to contact each other for three weeks—mobile phones did not yet exist and where we were going there were simply no telephone lines. My family would be in complete ignorance of my whereabouts. Once my worrying about the research program had faded into worry about my own safety and then into feelings of guilt and concern for my family, I finally fell asleep.

  * * *

  The following morning, we left Kinshasa. We were a team of about ten people and traveled in two heavily laden jeeps.

  As we drove through the outskirts of Kinshasa, a city with several million inhabitants, the communities looked more and more impoverished. The conventionally built-up center of the city was ringed with densely populated slums where living conditions were grim. We were driving east toward the rising sun on a two-thousand-kilometer-long road that crossed the entire country. The heavy traffic, consisting mainly of trucks, was dangerous because the tarmacked lanes of the road were so narrow. At first, we could get glimpses of the Congo River but then the road turned away and took us up onto the high plateau. We were on our way.

  The tarmac was riddled with potholes, which kept our speed well down. We took our first break in the small town of Kenge. A row of packed stalls lined the sandy road into town—everything a traveler might need was on sale there, including local produce like bananas and peanuts, and car parts, T-shirts and shorts. A tailor was on hand to mend torn clothes. Most of the travelers were poor so the goods on sale had to be cheap. Many traveled standing on the back of a truck, squashed in with thirty or so others. They had to carry water cans because of the exposure to heat and strong sunshine.

  The farther east we went, the clearer it became to me that we were entering a world of extreme poverty. The road lost definition and became a shapeless, sandy piece of ground. Nothing shows more explicitly and more cruelly how poor people are than the dangers they are prepared to face in order to travel to places they need to go. On the Congolese roads, journeys were full of risks. The relatively flat savannah landscape is crossed by deep valleys. The flat ground invited drivers to speed, while the old, badly-maintained cars ran into trouble in the valleys, often because of faulty brakes.

  Old car wrecks along the road were warning signs. A terrible accident had taken place along one stretch we passed. A truck was upside down and, on the grassy roadside, six corpses had been covered by sheets. The rescue work seemed to be directed by men with red crosses on their jackets. We pulled up alongside to find out if anyone required medical help. We learned that the truck, loaded with thirty passengers, had driven down into the valley at speed. On the downward slope, the driver had moved the gears into neutral to save fuel. The truck had careered across the bridge and started up the other side but the driver couldn’t get the gears to re-engage and it lost momentum. As the truck began to roll backward, the driver jumped out through the window and disappeared. The driverless vehicle missed the bridge and fell into the river. Some of the injured had already been taken to the hospital, six dead passengers had been hauled out of the water and many more were still missing. Since there was no more we could do, we headed on our way.

  The volunteers told us that unless some relatives came to identify the dead and take them away, the corpses would be buried next to the road. In a society without the resources to maintain decent roads and vehicles and provide sufficient traffic police, people have to work out their own ways of dealing with road-traffic accidents and the injured or dead victims.

  Just before sunset, we reached Masi-Manimba, a small town in the highlands, around six hundred meters above sea level. Most of the houses were simple dwellings with walls made of dry mud. The name of the town recalled the African sleeping sickness: Masi-Manimba means literally “the place where people sleep” in the Kikongo language.

  During the colonial period, teams sent out to identify the parasite that caused sleeping sickness had collected blood samples from local people. The village elders told us this when we met up with them the following day. They added that each of the village blood donors had been given a tin of sardines by the technicians.

  “It’s a serious matter, drawing blood from poor, hungry people. You must explain carefully why you’re doing this. And you need to bring nuns along to help. They return to villages year after year and are respected everywhere,” advised the head of the local health service.

  We said that we were very aware of this and that we were going to stay with the nuns in Lumbi. The mission had been set up by the Sisters of the Cross and Passion and the five nuns there, all of different nationalities, were known as “the passionate sisters.” Their small collective was to be our base for the next few weeks.

  The abbess was a wise, cautious woman. She agreed to let one of the young nuns join our scientific team. Sister Kalunga was Congolese, knew the local language and had just completed her nursing qualification. Her presence would strengthen what I thought of as the “chain of trust.”

  Toward the evening of that day, we set out to drive to the mission. The road was so poor it took us an hour to cover just twenty-five kilometers. The nuns gave us a warm welcome and showed us to the guest rooms.

  Then we had several meetings with the nuns to explain and discuss our research. We also decided that a local schoolteacher who spoke French as well as the region’s indigenous languages would accompany us to the villages. Her presence completed our chain of trust. The teacher’s loyalty and translation skills would later save my life.

  The nuns ran a well-organized hostel. In the evening we dined at a long table beautifully laid with a tablecloth, napkins, and jugs of iced water. Dessert was served after the main course and with it liqueur glasses were set out. The next moment, I spotted Sister Linda step into the room, smiling happily and holding a large bottle in her hands. I realized that this could become problematic. My Swedish colleague Thorkild was a Baptist and, as an active member of the church, would not drink alcohol.

  Sister Linda’s bottle turned out to contain homemade orange liqueur. Thorkild began to say something in his fluent French about not wanting any of the drink. The nun looked troubled and I intervened quickly, holding out my glass to show how keen I was to be served and simultaneously elbowing Thorkild in the midriff, whispering “Come on, it’s about culture—not religion. You had better drink the stuff and smile to show how much you appreciate these wonderful nuns.”

  Thorkild drank, smiled and chatted pleasantly with Sister Linda. She seemed to enjoy his many questions about making liqueur. What’s the method? How much sugar do you use?

  It mattered enormously to me that the nuns understood how grateful we were for all their efforts. These women were essential for our continued work.

  (Later, Thorkild got his revenge when we were eating with the villagers after a day of interviewing in a remote place on the savannah. Supper was fried rat. Thorkild whispered: “It’s all about culture, you know. You’d better eat this fried rat and show how much you appreciate these wonderful hosts.” I ate the rat meat with a smile. We got on just as well with the villagers as with the nuns.)

  Work began the next day. We divided the team to cover visits to twenty-two villages in the neighborhood. All were within a radius of about ten kilometers and could be reached by narrow lanes, sometimes only on foot. The first task was to introduce ourselves and our research program to the elders and the other villagers. When—and if—they accepted us, we would count the inhabitants and examine everyone with walking problems to find out wh
o suffered from konzo. The most densely populated and most distant of the villages was a place called Makanga and it was said to be particularly afflicted by konzo, with many paralyzed children. There, we were also to interview people about their diet and take blood samples.

  At work in the Congo

  It was my job to go there.

  * * *

  We set out in the jeep the next morning: Banea, the nurses, the teacher who would interpret, and me. It took us an hour. The narrow roads, sometimes just paths, crossed stretches of savannah and climbed up ridges with views over river valleys and deep clefts covered in rain forests. People were growing cassava on the dry savannah as well as on the slopes of the hills. They used whatever construction materials they could find for their homes: walls were made of sundried mud, and floors of flat-trodden soil, while roofs were covered with grass. Hardly any of the houses had doors.

  When the jeep rolled into Makanga, we were greeted by barefoot, thin children in worn clothes, who came running alongside us, full of charming curiosity.

  * * *

  We spotted at once that some of the children were limping, with the characteristic spastic leg movements of konzo.

  The village elder lived in a house at one end of the village and we pulled up outside it. He knew we were coming and had chairs for us arranged in a circle in the shade of a nearby tree. Some men, who seemed to be the elder’s advisors, chased the eager children away and then sat down on the ground nearby. We talked for an hour—an agreeable conversation. We described our plans and he asked us many questions about them. We waited until the elder’s questions had been answered, and finally we made a deal. Our interviewers would count the houses in the village, draw up lists of the size of each household and start examining everyone who had problems with walking. The elder agreed to our taking blood samples, provided all sampled people were given a tin of sardines, as they had been whenever samples had been taken during the colonial occupation. However, he and his advisors considered it unnecessary to bring everyone together for a collective explanation followed by a question-and-answer session.