How I Learned to Understand the World

by Hans Rosling

  I taught my students a different, three-stage approach to estimating how healthcare was used by people in the area.

  First, get as correct a figure as possible for the number of people who live in the area you serve. Remarkably few of those who had experience of work in distant places had bothered to find this out, despite the facts that all countries conduct a census of some kind and that hospitals usually have defined catchment areas.

  Second, get an estimate of how many children are born annually in this catchment area. In poor agricultural regions, the number of children born in a year is approximately 4.5 percent of the population. So, if the region has a population of 100,000, the expected number of newborns is 4,500.

  Last, find out what proportion of the children were born with help from healthcare staff. You get this figure by dividing the number of registered births, let’s say 1,100 in a year, by the number of expected births (4,500 in this example). The conclusion in this case is that only about a quarter of all births were supported by trained staff and that the other three-quarters of births took place at home with no known skilled assistance.

  Looking at vaccinations, if say 2,200 children are vaccinated against measles in one year and you compare that figure with the expected number of new births (4,500 in this example), you soon realize that half the area’s children are not getting vaccinated.

  Ex cathedra: perched on the desk

  These are the important questions. They do not relate to how far patients have had to travel.

  Many of my students resisted the notion that they needed such numbers in order to act ethically. They clung to the idea that the ethical choice was to treat those patients who had managed to get to the hospital as effectively as possible. They would not take on board the fact that for the majority of patients in poor countries, to travel was not an option. It was difficult to convince these students that, as the people responsible for healthcare services, they would do more good if they focused on offering the basics, such as iron tablets for pregnant women and vaccines for children, to as many people as possible.

  To me, the discussion of how to reach the poorest and most excluded was the core issue in my teaching. It went hand in hand with explaining how significant the differences in health service resources could be between different countries, even though all of them might have been categorized under the one label of “underdeveloped.” My explanations drew some strange responses, when students taking the course became aware of how much their target countries had developed over the last few decades. It could even make them disappointed and irritated. One day after lunch, when I returned to my office in the Uppsala Institute for International Child Health, a young woman was waiting for me.

  “I wanted to speak to you one-on-one,” she said.

  The preparatory course, scheduled to run for ten weeks, had only just started but I already recognized her as a very active participant. Her breathing sounded strained as she settled on the visitor’s chair next to my desk. Without saying a word, she put a letter in front of me with a hand that trembled a little. I noted the ornate letterhead with its elegant type. The sender was an official in Thailand’s Ministry of Health. The long message was written in English.

  “This is a rejection of my application for a work permit to be employed as a nurse in Thailand. Can you believe it! They are telling me I can’t go there to work in the Baptist-run hospital in northern Thailand. I have been planning it for ages and already signed a contract with the Baptist Mission.”

  The words poured from her. There was no mistaking how angry and desperate she felt. I was genuinely surprised. Via the Baptist Mission, Sida (the Swedish International Development Cooperation Agency) had funded her pay as a health service volunteer so her services would cost Thailand nothing.

  “Exactly! I mean, why refuse?” she said. I did not understand the rationale either. I offered to phone the secretary of the mission, who I knew was very experienced. But, the angry nurse in my office told me, there was no need.

  “I have already spoken with him. He explained that it’s Thai government policy to encourage hospitals funded by foreign states to employ only Thai nurses. He says there are actually unemployed local Thai nurses, though I find that hard to believe.”

  I promised her I would look into the matter. She left my office, dejected.

  The explanation in the letter from Thailand turned out to be perfectly true. Even back in 1972, Agneta and I had been impressed by the university hospital in Bangkok and, since then, Thailand had gone through a period of rapid social and economic development. In fifteen years the average per capita income had doubled and life expectancy had increased by ten years. It was reasonable that the country would prefer its own nurses to be employed in their home country. For one thing, they of course spoke Thai fluently.

  The angry nurse who had been refused a work permit for Thailand was only the first of many students who alerted me to the fact that the world needed different kinds of skills, and so if my course was to continue it would have to start recruiting different kinds of students. That change had already happened by the time I left the Uppsala Institute for International Child Health in 1996, after thirteen years, to take up a post at the Karolinska Institute in Stockholm. By then, the students in my course were mostly qualified doctors and nurses who had short-term contracts to work for Médecins Sans Frontières at emergency clinics in disaster zones. Many so-called “underdeveloped countries” had followed the same route as Thailand and even countries that were still very poor, like Tanzania and Mozambique, had as many local doctors and nurses as they could afford to employ. Indeed, Africa had already begun to “export” healthcare staff to Western Europe and the Middle East. The old kind of Western doctor who had worked in African missions for ten or twenty years was no longer needed and no longer existed, and similarly there was no longer any need for Western doctors and nurses serving for a few years in aid organizations.

  * * *

  I had been very engaged in teaching throughout these years but I did not hesitate when offered a chance to return to research work—by a man from the Cuban embassy who turned up in my office one day in 1993.

  He brought me a bottle of rum, arguably not the most appropriate gift to bring an expert in public health, and had an urgent reason for calling: an epidemic had started spreading in Cuba over the last few months. Characteristically, Castro’s regime had advised the media to keep quiet. The first sign of illness was a loss of sensation in the toes and then in both legs. The weakness could become so pronounced that the patient could barely walk. Sometimes, the sensory loss also included their fingers. As the condition progressed, the patient’s sight deteriorated, with large blind spots in their field of vision and changes in color perception. The underlying nerve damage was clearly very serious; worse still, the number of cases was truly alarming, at more than forty thousand.

  “We have decided to ask foreign scientists to study this condition and we would love you to look into it,” the embassy official said.

  I was certainly curious: scientifically speaking, the symptomatology was really exciting. But how should I design the research investigation?

  It did not take me long to realize that the embassy official wasn’t here to inquire about my interest; he was a messenger from someone who had already decided that he wanted my help. I was known for having investigated poisoning caused by cassava—roots that were also eaten in Cuba.

  “Can you come next week?” the embassy official asked me.

  “What are you suggesting? Why didn’t you come to see me earlier and give me more warning?” I asked.

  My daughter’s end-of-school exams were scheduled for the following week. In Sweden, this event, with all the surrounding ceremony, is a key rite of passage. I asked him if I could stay until after the ceremony, and then leave immediately afterward. He agreed.

  “Good. But the research will cost a lot. Do you have the money to fund it?”

  “Regrettably, we don’t,” he said.
“Because of the crisis.”

  At the time, Cuba was in the grip of a financial crisis that they had named el período especial, “the special period.” The Soviet Union, Cuba’s major trading partner, had initially saved the island economy, but the Soviet Union itself was going through its own political convulsions and collapse. Now, most everyday goods in Cuba, including food, were rationed, bus services were canceled, and electricity came on for a couple of hours in the evening but only in alternating districts. This was how the regime was trying to solve its problems, which, according to their frequently reiterated argument, were caused by el bloqueo—the blockade by the USA. In Cuba, they also spoke, but only in whispers, of el bloqueo interno—the internal blockade. For instance, you could not buy bananas in the streets of Havana because the farmers who grew them had to sell their produce to the state-owned company. This was due not to US sanctions but to the rigidity of state planning.

  I applied to Sida for travel funds and was offered a grant within forty-eight hours. The team at Sida were not fans of the Cuban government, but the Cuban population was obviously suffering.

  Preparations were made swiftly. Before long I was on a flight to Havana with Per Lundquist, a chemist from Linköping University. Once we arrived, we were in Cuban hands. “We’ll meet you at the airport,” they had told us. As soon as we descended the steps from the plane we were led away and driven to a VIP lounge where we were welcomed by a large reception committee. Two obviously important figures singled themselves out from the crowd: a man with crisply pressed trousers and polished shoes, and a woman wearing very red lipstick. The man introduced himself as the deputy minister of health and the woman as director of the Finlay Research Institute. Its name commemorated the Cuban epidemiologist Carlos Finlay, who had discovered that yellow fever is spread by mosquitoes.

  I was discreetly informed that the woman, known as Conchita, was also a member of the politburo. It was clear that this was a very big thing: a member of the highest echelons of the Cuban Communist Party had come to meet me.

  The following day we were collected from the hotel and driven to the Finlay Institute. The Cuban medical scientists who had been working on the epidemic—epidemiologists, clinicians, and laboratory scientists—were waiting to meet us. The atmosphere was tense with expectation. I felt like water in the desert, so eager were the Cubans to talk to foreign colleagues. Their presentations about the epidemic, who had been afflicted and where, were first class. Most of the cases had been found in Pinar del Río, a tobacco-growing province. We all lunched together and then returned to the laboratories, but we had hardly started working before the main door suddenly opened and several men came in. They moved about without making a sound because they all wore gym shoes. Each carried a handgun in his holster. They positioned themselves in the corners of the lab.

  Then the boss entered. Fidel Castro.

  I caught sight of his profile and just had time to think, “That’s Fidel Castro.” I had seen him on TV before and heard excerpts of his shouty speeches. The man now in front of me reminded me of the generously bearded Beppe Wolgers, the Swedish actor and poet. Castro gave himself time to greet the people in the room and ask after everyone’s families. When he caught sight of me, he broke into a slow jog and advanced toward me with open arms: “El sueco!” he exclaimed—the Swede!

  I introduced my Swedish colleague but Castro was obviously more interested in me.

  “What were you discussing when I came in?” he asked.

  I told him about the course I was teaching and Castro asked questions about Mozambique and its socialist president.

  “So, you worked in Mozambique when Samora Machel was president, and as a young man you joined the Social Democrats?”

  At first, I couldn’t think where he was going with this. Then I realized that he had memorized my CV and was checking it.

  “May I say something?” I decided to ask.

  “Yes,” he replied, sounding a little curious.

  “Mr. President, I would like to thank you personally, on behalf of all public health researchers. You have stated publicly that you have stopped smoking, even though you have long been identified with a fondness for large cigars. Indeed, you are in charge of a tobacco-producing country. It was a very significant statement.”

  He laughed. The others in the room laughed with him, in a manner that is characteristic of people who work under a dictator. It is artificial laughter but not false; well-meaning but going on for a little too long. The dictators appreciate it for what it is: a show of respect.

  Once Castro had left the room, our discussions resumed. The Cubans were intensely serious about their task and were happy to have us, but they must have wondered exactly why we were there—the epidemic was actually on the wane. However, they still did not know what had caused it. The intention behind our invitation was probably two-fold. In the first place, it was important to establish that the epidemic was not infectious. Second our presence showed the Cuban people that the country was open to international science.

  The following day we were shown around hospitals in the capital and introduced to patients. In the ophthalmology department, I was impressed by the advanced treatments available for patients with sight problems. Consultants and groups of doctors specialized in discrete conditions such as cataract surgery, glaucoma, diabetic retinopathy, and so on. My Cuban colleagues responded to my curiosity and relished my clear admiration.

  That evening a meeting had been arranged for us with members of the politburo and the Academy of Sciences. We met in one of the academy’s meeting rooms in its official home, a three-story concrete block. I had been asked to tell them about my impressions of the Finlay Institute and the hospitals we had been taken to see.

  The conversation began smoothly but then I moved on to question their methods. Finding out what individuals have been eating is one of the most difficult things to investigate, even when the subject does their best to describe everything in detail. The inquiry must establish not only what the subject has eaten but also how much of each item, how it was cooked, and where it came from.

  “I think you have been using the wrong methodology to find out about people’s food intake,” I said. “You have simply handed them a questionnaire. How can you be sure that what is written down is a correct account? For one thing, what about any informal trade in food stuffs? Is it possible that some toxic component might have been smuggled into Cuba?”

  “The island is shut off so that’s impossible!” someone exclaimed.

  They laughed but were clearly feeling defensive—not because they were loyal Cubans but because they were very skilled quantitative epidemiologists. They had mastered and refined numerical methods for calculating and comparing exposure to risk factors between groups of ill and well people. It was a bit much to ask them to tolerate an anthropological approach that called for varying questions asked in an open interview format, and which even assessed facial expressions and body language. To them this was fluffy methodology. At the time, in the 1990s, there was strong opposition between these two different ways of working.

  Suddenly, the door opened and the silent men in gym shoes entered and distributed themselves into the corners of the room once again.

  Castro followed. As before, I had had no pre-warning. Later, I realized that the entire meeting in the Academy of Sciences had actually been engineered to create a meeting between me and Fidel Castro.

  He sat down in the armchair next to me. I praised the presentations we had seen.

  “What do we do now?” he asked.

  “My job is to find out whether something people have eaten might have caused the epidemic.”

  “But the team have already investigated everything.”

  “No, they have not investigated everything, because they relied on questionnaires. The list of questions focused only on the topics the investigators had already considered. No one has investigated what hasn’t yet been considered.”

  The methodology discussi
on started all over again.

  “Are people really telling the truth about what they have eaten? After all, the epidemic occurred during a período especial,” I said.

  He interrupted me and his tone was now harsher.

  “I assure you, the Cuban people have the greatest confidence in our health service.”

  We were at a conversational dead end and no longer understood each other. Castro was visibly irritated and the Cuban scientists and officials shifted about restlessly in the large room, looking as expressionless as fish, while some exchanged pained glances, then stared down at the table top. They seemed eager to leave the room.

  “May I tell you a story?” I asked.

  I heard the words coming from my mouth. Castro seemed a little uneasy.

  “A story? Of course, go ahead.” Our eyes met.

  “When I was a young student, I watched footage of you and Che Guevara arriving here in Havana. You had come from Mexico in the ship Granma to start the Cuban revolution.”

  “You have seen it?”

  “Yes. It was filmed in black-and-white.”

  “Do you remember the moment we stepped on land?”

  “No, I don’t. I remember seeing you on board the ship. And then you were on land.”

  “True. We never filmed the landing.”

  A typical dictator’s device, testing me.

  “But I saw the footage of the time when you lived among the people in the Sierra Maestra. You learned about their living conditions. You had been a privileged student beforehand and had never lived among people in remote regions. At first, you did not understand them.”

  “That’s true,” he said.

  “I remember seeing you sleeping in a small wooden shack and working with the Sierra people in the fields. You helped the children with their homework and the women with the cooking. You must have come to understand them well?”

  “Yes. I understood them,” he said.

  “Still there was one thing that surprised me. Something I did not see in the film. It was completely absent.”