How I Learned to Understand the World

by Hans Rosling

  “What do you mean?”

  “There were no questionnaires!”

  Most of the listeners could not see the point but Castro did and he laughed.

  “I want to follow your example and do what you did. I want to take a team of researchers to Pinar del Río and find out exactly how people live. We might find something unexpected. This kind of research is what I call open-ended,” I explained.

  Then I added a sentence that made Castro’s face really light up.

  “Today, your approach in the Sierra Maestra has become research methodology.”

  He left after that. No agreement had been reached.

  The following morning, two men were waiting for me when I came down for breakfast. One of them wore a military uniform and stood to attention. The other was a civilian. They were, respectively, the Cuban commander in chief and the minister of health. Their message was that El Comandante wanted me to stay for six months, with complete freedom to plan my work.

  My head spun. Six months? There I sat, facing two of Cuba’s most senior state officials, who insisted that I should stay. At home in Sweden, my family was waiting for me. I had intended to spend the summer with them. I must phone Agneta.

  “Oh, it’s you!” Agneta said at the other end of the line.

  We had not been in touch since my arrival in Cuba, so I began by describing the situation in general. Later, I would have to be specific.

  “Gosh! Have you really met Castro?” she exclaimed.

  I told her what the Cuban government had in mind and suggested that I should stay for three months. Halfway through my time here, she and the children could come to Cuba for a week’s holiday.

  Agneta stayed quiet and listened carefully.

  “Sounds good,” she said, in her usual straightforward way.

  * * *

  The following day, we had to plan. We began by drawing up detailed maps of the geographical spread of the epidemic. I had been allocated a few additional Cuban colleagues to help with the work, including Mariluz Rodriguez, the epidemiologist in charge of the most affected province. She had worked in Angola for a long time and was incredibly good at her job. Mariluz was frank and spontaneous. Professionally, we had a lot in common. She had a mane of red, curly hair and wore very red lipstick. It was clearly a national style choice. I had never seen such bright lipstick as in Cuba.

  It was thanks to Mariluz that I came to understand what the Cuban crisis, that special period, really meant. One Saturday night, she had invited me round to have a meal with her and her husband. He was sitting next to her, holding her hands because they were so sore. It had been laundry day: the family’s clothes and bedlinen had to be washed by hand in a cement trough with a corrugated inner side. Since neither washing powder, liquid soap, nor ordinary soap was available to buy, Mariluz used salt, which ruined the skin on her hands. It was remarkable: one of the leading specialists employed to control an ongoing epidemic had had to spend half her Saturday laundering sheets in salt solution. Still, Mariluz supported the regime. She called herself a revolutionary and was proud of the achievements of the revolution, especially the health service. She had been there from the beginning and had devoted her life to working in public health, including the eventual control of tuberculosis and the introduction of decent toilets for everyone. Being part of the Cuban health service was a source of great pride.

  We began our investigation by conducting what I call semi-quantitative interviews with two different groups: one group was from an area with many patients who suffered from paralysis and the other was from one with few. From the data, it emerged that in areas where there were private farms they had very few or no cases. After the revolution, Cuba’s large farms had been nationalized but the smaller ones had been left in private hands.

  In order to interview the farmers in peace, away from the prying eyes and ears of the regime, we employed a method that I had devised in Africa. When we first arrived in a community, I would spend time with the local power brokers. In the party meeting rooms, decorated with pictures of Lenin and Marx, I held court with the secret police, who were curious about the foreign doctor. To make myself look important, I brought along a list of questions for them, all unrelated to the investigation. I also offered to measure everyone’s blood pressure. Meanwhile, the interviewers—junior doctors who were all women—were given the space and time to chat with the local village women and carry out the job they had come to do. Much can be managed by manipulating people’s curiosity.

  While I was working in Cuba, Castro would often mention me and my work and the state newspaper would write up stories about “the Swedish doctor” who had sacrificed his family holiday to come and work in Cuba. Castro told his people that “you won’t get any holiday either” and many citizens became angry with me.

  The party bosses wanted me to appear on state TV to explain my research. I managed to get out of that. Working in a dictatorship requires you to be very precise about your role. Why was I working in Cuba? My task was to try to understand the cause of the epidemic. While I was there, I must not quarrel with the authorities but also must avoid being exploited by them. Above all, I must not be a source of harm to my colleagues. It is essential for the visitor to accept that local people live with certain constraints. For example, the kinds of conversations that Swedes might take for granted were kept strictly private and simply never took place in public in Cuba. You must be alert to the signals that someone is prepared to speak openly, but you cannot force their decision.

  My family did come to spend a holiday with me and then my daughter, Anna, stayed for a while longer. She had made friends of her own age in Cuba and went dancing with them in salsa bars. Her friends had cars, but to use them they needed petrol bought on the black market. My daughter visited apartments where black-market fuel was stored in bathtubs and she haggled over prices with drivers. She got a lot of insight into the trade in goods, including the prices; we had developed a new investigative methodology known as daughter-goes-dancing-and-talks-to-the-locals. When she came back after a night on the town, I would sit on her bedside asking for details until she pleaded that she was exhausted and just wanted to go to sleep.

  Anna’s stories about the nightlife in Pinar del Río really helped me to understand more about Cuban society and the role of the black market. At breakfast, while Anna still slept, I would tell my fellow epidemiologists about our latest findings.

  During the daytime we collected data and, in the evenings, we would collate and tabulate what we had learned. By midnight we had usually finished work and the guitars came out. There was always someone who played “Cuba, qué linda es Cuba,” “Cuba, how lovely is Cuba.” I fixed beers for everyone from our foreigners’ rations—my allowance was two or three bottles per day.

  As time went by, we found we could now draw a graph based on our data, a curve showing the number of new cases per day. And were there any aspects of the graph that coincided with external events? We could observe social factors: those who had contacts in foreign countries were less affected, for example. There were about ten thousand cases of the illness in Pinar del Río. As we initially noted, small-scale farmers were much less afflicted than the workers in large tobacco plantations, who tended to be undernourished.

  It seemed unrealistic to imagine that the Cuban government was unaware of the black market. Nonetheless, my colleagues had never heard of any state registration of the black market pricing systems.

  “Quite out of the question,” they assured me.

  I did not believe them.

  “Come on, can’t we speak with the provincial governor? He should know, shouldn’t he?”

  Everything about this idea made my colleagues feel uneasy, but they agreed to book me an appointment with him. The governor was seated at a desk overflowing with papers when he received our delegation. I outlined our findings so far, stressing that farmers who worked on small, privately owned farms escaped the illness, while plantation workers who had relatively litt
le to eat were often afflicted.

  The governor was very interested and enthusiastic.

  “We believe that people who can afford to buy food from unofficial sources are protected against the illness. Are you aware of how the prices move in the market?”

  Now he became serious.

  “What do you mean?” he asked.

  “Well, let me explain. In Sweden there is no shortage of food. However, we do struggle with the trade in illegal drugs—a problem you don’t seem to have here.”

  I launched into a vivid account of how drug-dependent Sweden had become.

  “Heroin, amphetamines, cannabis. All on the black market, of course. Still, the police do what they can, using informers who report back on prices in the market. They can determine when a delivery has come in because the prices fall.”

  “Now that’s very interesting! We use the same approach here,” He looked at us all in turn. “We call it Instituto de la Demanda Interna—that is, the Institute for Internal Demand.”

  My colleagues had gone silent and the atmosphere was tense.

  “Would it be possible for us to see someone at the institute?” I asked cautiously.

  Castro had given me the all-clear, after all. Before long, we were standing outside a modest, unmarked door.

  “We have been expecting you,” said the man who opened the door.

  Inside, a large woman sat waiting for us. Her shape was startling—food was scarce that summer and it was rare to see anyone overweight in Cuba. She told us that her unit was in charge of compiling data on oil and meat prices. In a dark room with drawn curtains we were shown the data and allowed to copy down the figures by hand.

  While the head of the unit and I got into a discussion about the best method of collecting data, as one would with a professional colleague, my companions kept quiet.

  They remained silent in the taxi back to the hotel, but once we sat down together to talk, I said enthusiastically:

  “See, I told you they had something like this!”

  I was thrilled with my findings and felt a little superior. But then I sensed the atmosphere: the others were subdued, even sad.

  “Unbelievable! This is completely unbelievable. How is it possible that you should discover this? You, a foreigner who has been here for a month! I trusted that our state would not be run in this way. Clearly, I’m more revolutionary than the revolutionaries,” one of them burst out, looking at a colleague.

  A wise regime that finds itself unable to feed its population will allow the black market to manage its trading but under supervision. Cubans had fought for a new society and believed they could live without free enterprise, but found they needed it to survive. The bright red lipstick, for example, was imported by sports teams, who went shopping when they competed abroad. Lipsticks were perfect for the black market: they combined high value with low volume and were easy to transport. Of course, not everyone could afford one, but there would be a lipstick owner in most tenement staircases. You sought her out when you needed a boost and paid her a fee in return for a slick of color on your lips.

  Our investigation into Cuba’s paralyzing illness came to a close when we demonstrated that the epidemic was unquestionably linked to people’s monotonous diet, triggered by the food shortage after the fall of the Soviet Union. Many would fall ill because they gave any meat and eggs available to the children and the elderly. The most heroic Cubans survived on rice and sugar, an extremely dangerous diet, lacking in vitamins or protein. Sugar was always available on the black market—the Cubans joked about it: breakfast was sopa de gallina—meaning chicken soup, but actually now redefined as just sugary water.

  The results of our investigation were handed over to the government and my Swedish colleague and I returned home. Before we left, we promised not to describe the condition in our official report as “toxic nutritional,” that is, as a combination of under-nourishment and poisoning. It was too politically sensitive to say the food supply in Cuba was insufficient. Instead, the favored classification was “toxic metabolic,” indicating that non-poisonous substances had been metabolized into toxins in the body.

  We had had no warning about the gathering at Stockholm airport, where a team from Swedish state television was waiting to interview us on our arrival. I was quite unprepared and had not discussed with the Cuban authorities how I was to handle publicity in Sweden. I ought to have told Castro before I left that, in my country, ignoring questions from the media was not an option.

  The news agency Reuters cabled the news of our findings worldwide: Eminent Swedish doctor says food in Cuba was so scarce and bad it made people ill. The Cuban government did not take kindly to my statement and our collaboration ceased. I didn’t talk about the investigation again.

  But time passed and things calmed down. Several years later, I was invited back to Cuba to give a lecture to the Ministry of Health on “Cuban Health from a Global Perspective.” In my lecture, I pointed out that Cuba’s child mortality rates were the same as those in the United States, despite its comparatively much lower per capita income. I was wildly applauded. After my presentation, the minister leaped up on stage and thanked me very warmly.

  “We Cubans are the healthiest of the poor!” he exclaimed.

  Later, a young man joined me at the coffee machine. He took my arm and gently led me away from the crowd. Then he leaned toward me and whispered:

  “Your data is correct, but the minister’s conclusion is wrong. We are not the healthiest of the poor—we are the poorest of the healthy.”

  Then he walked away. He left me with a smile on my face because he was right. What was remarkable about Cuba was not their advanced health service but the colossal failure of the regime to create economic growth and freedom of expression.

  To this day, I have never published the results of my investigations in Cuba. I did not want to create problems for the people I had been working with there. Nowhere in the world had I come to care more for my colleagues.1

  The task I was given in Cuba was unusually dramatic and very unlike most research, which is often dull. Persistence is the most important characteristic of a researcher. But now and then there are moments, often years apart, when you have the hugely gratifying feeling of having discovered something.

  * * *

  By 1996, I was running a five-week course in global health at the Karolinksa Institute in Stockholm. It was a very popular course, not least because the students spent the last two weeks abroad. Every term, our course would be chosen by around thirty of the institute’s one hundred medical students.

  But after a couple of years a new idea took root in my mind: I was concerned that the course was only attracting those students who already knew about global health. I wanted instead for the course to be compulsory for all medical students. To present this plan convincingly, I needed evidence that, before they joined the course, our students knew much more about the topic than others. One of my graduate students, Robin Brittain-Long, offered to have a go at finding out if this was true. We agreed that Robin would compare two groups, one of students who had chosen my course and one of students who had chosen a course in intensive care, a subject with wider appeal.

  When Robin first showed me the results of the study, I was rather disappointed. It showed that prospective students with an interest in global health knew no more about the subject than those who had decided to take the intensive care course. Shit, that’s me proved wrong, I thought.

  But then I looked more closely at Robin’s data and what I saw made the hair on my arms stand on end and a shiver run down my spine. My heart beat faster and I almost stopped breathing when I realized just how awful the results were. One question was especially revealing: “Below are five pairs of countries. In each pair, one country has a child mortality rate twice as high, or more, than the other. Please select the country with the higher mortality rate.” All the pairs consisted of one European and one non-European country. Child mortality is one of the most useful measur
es of a country’s socioeconomic development. To choose the correct answer in each pair, the student needed a rough idea of which country was the more developed. Given that there were only two options, if they picked countries at random, half of the answers should have been right.

  Yet the students managed to get only 36 percent right, which means they performed worse than if they had known nothing and relied on luck.

  This was why the hair on my arms stood on end: responses that were worse than chance implied some incorrect assumption or prejudice. Far too many of the students assumed that child mortality would always be lower in Europe than in some rapidly growing Asian countries. However, by 1999, South Korea had less than half the child mortality of Poland, which was also true of Sri Lanka compared to Turkey, and Malaysia compared to Russia.

  When I had calmed down, I realized that Robin’s study opened up a startling new perspective: education about global health was not about filling knowledge gaps. Its proper function was to remove preconceived opinions, particularly that “the West” is always more developed than anywhere else in the world. The other key finding was that even students with a strong interest in the world around them did not necessarily know more about it than their less-interested peers.

  A quarter of a century had passed since Agneta and I had been shocked at our own unpreparedness for the advances we saw in Southeast Asia. Twenty-five years later these Swedish students still had not noticed how quickly that part of the world had been catching up with Europe, and that many Asian countries were now doing better in some respects than parts of Europe.

  * * *

  Before taking up the post at the Karolinska Institute, I had spent almost ten years teaching global trends in healthcare and population growth at the University of Uppsala. I had met many smart, highly motivated students with strongly held, preconceived ideas about what was going on in the rest of the world. It was obvious that the Swedish education system had failed to give them even a rudimentary knowledge about the world beyond Europe.