How I Learned to Understand the World

by Hans Rosling

  “This village is too large for that kind of thing. They’ll do what we’ve agreed here. I’ll come with you. They trust me,” the elder said with a smile that turned into a laugh.

  We also asked to rent an empty house where the blood samples would be taken and where we could keep our small diesel generator and the centrifuge machine we needed to separate the blood. We wanted to keep the curious—children and adults—at a certain distance.

  I insisted that we should talk to the families who gave blood samples, even though I had accepted that we could start the counting without first arranging a big meeting for everyone. I checked with the interpreter that my point had been clearly translated and understood. The elder agreed and said that this could be done the following day outside our makeshift laboratory. We also followed our usual practice of employing two local teenagers, a boy and a girl, to help with the work in the lab. It was a good way of creating a wider understanding of what we were up to and, besides, visitors offering job opportunities are always popular. In addition to their modest wages, the two young people would be given a certificate stating that they had participated in a research project.

  We had spent time thinking through the details of the visits and we were relaxed about the pace of things. There should, we felt, be plenty of time for discussion, which required more time because everything had to be translated. Most of the villagers spoke several languages, but they communicated with strangers in Kikongo, the lingua franca of the southern Congo, rather than in French.

  The first day was free of trouble, and we were accompanied around the village by the elder, as agreed. He asked people, apparently very kindly, to tell us how many people lived in each house and who had problems walking. I noticed that from time to time his voice became quite harsh, but no one seemed to protest. When we had finished the count, we inspected the building that would become our laboratory, a small structure with a straw roof and walls made of mud bricks. I chatted with the two teenagers who had been picked by the village elder to assist us. Once our tasks for that day were done, we drove back and returned to the nuns at sunset. They were waiting for us and had prepared another splendid dinner, with a glass of orange liqueur. Before doing anything else, we walked down to the river and washed off the dust of a day on the roads and in the village. The mission guest rooms were very clean but had no running water.

  The following morning, we loaded the jeep with a small diesel generator to power the centrifuge machine. The blood samples had to be spun so that they would separate into parts, and then stored in large steel thermos flasks. All this equipment looked interesting to the locals—nothing like it had ever been seen in the village before. When we had parked the jeep and started unloading, people came along to have a look. Our two local assistants turned out to be very useful. Their first task was to explain to the crowd what we were doing. At the same time the interpreter and I and our two assistants started to set up the equipment. Banea walked off to prepare for the interviews. I was feeling upbeat as I began. The hut had been cleared and cleaned as I had requested. There I was, installing essential equipment for the research project we had been planning for two years. It was satisfying. I started up the generator and tested the centrifuge. It made quite a lot of noise and, for a few minutes, I could not hear what was going on outside.

  When I shut the centrifuge down, I picked up the sound of angry voices. My mood changed in a few seconds. I crouched down to get out through the low doorway and when I straightened up again, I realized that the whole area around the lab hut was full of people who sounded very upset indeed. They must have seen how frightened I was. Suddenly, their voices became louder and along with the many fingers pointed at me, two men raised machetes and waved them about in a very threatening manner. The man closest to me seemed especially ill-tempered. The arm holding the machete had a scar running all along it. I was as scared of machetes as of guns. As a medic in Mozambique, I had cared for several patients with grave injuries inflicted by these weapons. One woman had had her face slashed from ear to ear at a level just below her eyes. The cut had severed the tip of her nose and exposed her nasal cavities. I had spent an entire afternoon stanching the hemorrhage.

  My one hope was the crowd of people separating me from the machete-waving men. During this panicky moment, the only familiar face I could see was the interpreter’s. He had come to stand next to me in the doorway. Loyalty had made him join me as the crowd grew.

  More and more people were arriving. The interpreter leaned closer to me and whispered, “The others have left.” He meant the rest of the research team, and sounded very frightened.

  “I think we should run,” he said. “They are very angry.” In just a second, my fear intensified sharply. I grabbed the interpreter’s wrist and held on to it.

  Two thoughts went through my mind.

  The first was that without the interpreter I would be lost, because it was only through him that I could communicate. The second was the memory of what I had been taught by the provincial governor in Tanzania, after another, rather less dramatic, confrontation with a man brandishing a machete. The man had become furious with me because I had taken a photo of his wife without asking him first. I had solved that conflict by holding out the camera in my hands, palms up, when he ran at me with his weapon.

  “You did the right thing,” the governor said afterward. “Never turn your back to an angry person who is threatening you with a machete. He is ten times more likely to try to cut you down if you run away.”

  I glanced left and right for an escape route. Not a hope. If the people wanted to hurt me badly there were more than enough of them to hold me down and let the man with the machete have a go. My only choice was to talk myself out of this.

  Fearful, I raised my arms and almost whispered: “Wait. Attendez. Attendez.”

  The teacher translated. Without letting go of his wrist I managed to get a grip on a wooden box standing just inside the door and turn it upside down. Then I stood on it. My fear drove my mind to form a few sentences in French.

  “I’ll leave at once if you don’t want me here. But I can explain why I am here.”

  “Tell us, tell us!” a majority called out, clearly not so outraged that they could not wait for a bit.

  “I have come to find out why your children cannot walk anymore.”

  “You have come to steal our blood!” a voice shouted.

  Slowly, I carried on explaining. I had studied the same illness in Mozambique and Tanzania. They were not impressed. I said something about drying the cassava root for too short a time, but most of them protested.

  Suddenly, after perhaps only a minute or two, a middle-aged woman stepped forward. She walked straight to me where I stood, perched on the box. Exactly in front of me, she turned to face the crowd. She raised her arms in an eye-catching gesture and addressed her neighbors in a loud voice:

  “Do you remember when our children were dying like flies because they had measles?” She continued: “Then, they brought the vaccine, and ever since, the nurses vaccinate our newborn babies, and our children no longer catch measles and die.”

  She paused for dramatic effect and took a step forward.

  “How do you think they knew about the vaccine? Where did they find it? Do you think vaccines grow in the trees of faraway countries? No, of course not. They understood how to go about making the vaccine because of what this doctor calls research.”

  She spoke in a measured tone, one sentence at a time. And as she uttered the word “research,” she turned round to point at me. Then she looked back out over the crowd where the two men with machetes stood waiting.

  “The doctor says that he and the two Congolese doctors are here to find out why so many women and children in our village lose the ability to walk because of the illness we call konzo. He does not claim to be able to cure it here and now. But if it is possible to find out why so many of us are stricken, perhaps we can get rid of konzo just as we got rid of measles. It makes sense. Here in
Makanga, we need this research.”

  She turned her back to the villagers, took a step toward me and reached out her arm. She pointed with her other hand at the inside of her elbow and exclaimed: “Doctor, take some of my blood!”

  Her speech had taken little more than a minute but the effect was startling. The men stopped waving their machetes about. Expressions changed from fury to smiling recognition. Shouting was replaced with gentle voices as people started to queue up behind the woman. While most of them joined the queue quickly, a few walked off with the machete-wielders.

  I remember exactly what was said back then, in a small, isolated Congolese village. Twenty-eight years have passed since that day but I can still recall the woman’s address as sentence by sentence, she transformed the crowd’s fear and aggression into sympathy and understanding.

  I will never forget how she saved my life.

  The rumors that we visitors had sinister reasons for collecting blood had spread like wildfire. In less than an hour, they had stirred up fear and fury. This was because of an ancient notion that you could be harmed by having some of your blood taken from you. It was not surprising that this misunderstanding should exist in an isolated village in the Congo. I had dreaded incidents like these, which I knew could happen if any link broke in the chain of trust.

  It wasn’t just the woman’s insight that saved me from death by machete, but the way she expressed the logic behind her argument. She changed her fellow villagers’ way of thinking so that they could see that their fears were the outcome of hasty, emotional responses.

  Over two decades of visiting distant places, I would meet other women like her. They would tell me how much they hated their poverty, and how they dreamed of education and decent healthcare for their children. And a nice, comfy foam-rubber mattress to sleep on. It was my memories of these women that would later make me confront the opinions of my Swedish students who argued that the poor were happy with their lot and should carry on being poor—“They mustn’t live the way we do, it would ruin our planet.”

  For many years, I continued to spend around a month annually conducting field studies in small, remote communities in the Congo and other African countries. Together with graduate students and postdoctoral colleagues, I published a long series of scientific papers and, eventually, the disease we had described became a standard entry in neurology textbooks. We also developed new analytical methods and even had patients flown to Sweden for advanced neurological examinations. Our observations confirmed the hypothesis that konzo symptoms follow the sudden decay and death of nerve cells that conduct signals from the brain to the musculature of the lower limbs. The condition occurs only among extremely poor people living in isolated communities, who become wholly dependent on cassava as a basic foodstuff. It strikes individuals who have existed on a diet of badly prepared—and therefore poisonous—cassava roots for some four to six weeks. Regrettably, the nerve damage is permanent, but the paralyzed person can be to some extent rehabilitated by using lightweight crutches.

  Despite these findings, I was gradually losing interest in the medical, toxicological, and biochemical aspects of the disease. Instead, I was keen to look into the underlying causation. The agricultural economy was driving a vicious circle of deprivation and extreme poverty.

  5

  From Research to Teaching

  The roll call had been done. My first lecture was due to begin. During the lunch break, I had smuggled the small blanket into a drawer in the teacher’s desk. No one knew it was there.

  My job was to tell around thirty trainee doctors and nurses what it is like to provide healthcare in the least developed parts of the world. Many had already signed contracts for posts in distant, extremely poor places. I was meant to explain how they should go about their jobs.

  That moment, just before the first lecture, was magic. I had never seen such eager and motivated students. They were a little shy of each other, though. Some had chosen this line of work because they were members of the Pentecostal Church, others came from charities with roles in Africa. When we polled the students’ voting preferences, the majority of the recruits to the course were either Christian Democrats or left-of-center Social Democrats. Even their dress style provided clues: some had their hair nicely done and wore clean, buttoned-up shirts and blouses, and others slouched in unwashed jeans. But they all showed an intense interest in hearing what I had to say.

  “I’m going to introduce this course by telling you an anecdote that I heard from the minister of health in Mozambique,” I started, as I pulled the piece of material out from its hiding place. When I was working there as a doctor, I had to struggle with very limited resources. The minister’s story was about a very small blanket.”

  In lectures, timing is all.

  “Though the story is really about a man,” I went on, pointing at myself. “He was walking in the Mozambican mountains when night fell. He was sleepy but it was cold and all he carried with him was a small blanket. How to make the best use of it?”

  At this point, I lay down flat on my back on top of the desk. Some of the students burst out laughing at the weirdness of my behavior. Others looked deadly earnest and a little uncomfortable. All were clearly thrown off balance a little. That was a good thing. I had caught their attention. I scanned the audience.

  “I had better wrap the blanket round my feet, the man thought.” I put the tiny blanket on my feet. “But then his body became very cold. So instead he put the blanket across his belly.” I moved the piece of material to my hips.

  “But now both his hands and his feet were freezing. He curled up but it didn’t help. He had the idea to wrap the blanket like a turban around his head. That didn’t work either. He still couldn’t sleep and it made him angry because he was so tired. ‘It must be possible to make the blanket bigger,’ the man thought.”

  Now I stood up on the desk, put my foot on one end of the blanket and pulled energetically at the other end.

  “I need to make it bigger!” I shouted. And I tore it in half.

  The students laughed but were still at a loss to understand what I was really trying to tell them. Immediately, I began to explain.

  “Don’t react like this man when you work in faraway healthcare systems. Don’t push your staff beyond what is reasonable and don’t imagine you can offer treatments like those available in Sweden. You must be wise and use ‘your blanket’ the right way. And don’t wear yourselves out. You have to stay in one piece, at least for the duration of the contract. How best to use limited resources in situations of great need is precisely what this course is about.”

  Goofing around with the blanket was therapeutic for me. I had lived with a great deal of frustration during my years in Mozambique. When I got back to Sweden, I wound up teaching this class from 1983 to 1996. It was the very same course that Agneta and I had attended all those years back, before setting out for Nacala: Healthcare in Underdeveloped Countries. I took on the job because it was easy to combine with my annual field research in Mozambique. Between teaching periods, I could take the research months off with full pay on the condition that I also worked as a consultant to aid organizations. Gradually, my identity changed and I never went back to practicing medicine. I had turned into a scientist and an academic teacher in global healthcare.

  The course was divided into three parts. One third was devoted to the care of mothers and children. One third dealt with viral infections in places of extreme poverty. The remaining third concentrated on how to organize and lead a healthcare system that has to function with perhaps as little as 1 percent of the resources available in Sweden. The students were exceptionally motivated: they had all signed on for specific healthcare jobs in some of the most impoverished countries in the world, generally for two years. The first two parts of the course suited them perfectly because the course content was all about how to treat patients.

  The third part was more challenging. Everyone easily grasped the importance of learning about malaria and
parasitic infections but most were surprised at being asked to learn how to estimate numbers of required staff, or figure out rates for fuel consumption, or draw up an annual budget for a mobile vaccination team. When, at the end of the course, the students were asked to evaluate it, many commented that learning more about laboratory test methods would have been preferable. But after they had been out in the field and were again presented with an evaluation form, the majority said they would have liked to know more about management, staff training, and budgeting. That was why it was such a help in my lectures to draw on the experiences of students who had already worked in low-income countries.

  Most of these students had worked for religious missions and learned ineffective methods for recording how their services reached the population, whether it was support for pregnant mothers and maternity care, or the treatment of children with malaria, or injured patients requiring surgery. They had been taught to record how far the patients had traveled to reach the field hospitals or mission clinics, to gauge the effectiveness of the services being offered. When Médecins Sans Frontières (Doctors Without Borders) began their work, it turned out that their staff were also using the same old “How far did the patient travel?” question to determine how well they were serving their populations.

  This method takes no account of population demographics.