by Hans Rosling
“Please excuse us. We’re disturbing you,” we said cautiously.
“Not at all, don’t worry,” the nurse said. Then he turned to the woman and asked her if she minded if he chatted to us for a while.
We introduced ourselves, explaining that we had worked in the hospital thirty years ago. The nurse, who was probably not yet thirty, said he had heard that foreign doctors had worked there once upon a time. His job, he told us, was to look after the rights of women.
“I help women to take crimes against them to court. I take care of inheritance claims as well, and prepare statements to be given to the police,” he said.
We were utterly taken aback. When we had worked in Nacala the level of violence toward women had been grotesque. It is often the case in extremely poor communities, and no one had seemed ready to change it. Now, with basic healthcare being provided, the system had moved on to attacking gender-based crime and defending women’s rights. The nurse gave us a small information brochure.
The old building that had housed the outpatient clinic in our time still performed the same function but had now been improved with a veranda running along the front. The shade was a good idea. At one end was a smaller building for the expanding dental service.
The district where I had worked in 1980 had at that time never been served by more than two doctors. Now it was looked after by sixteen medically qualified people and a new hospital had been built. The hospital manager was the most clinically experienced of the doctors working there, a highly qualified and competent Mozambican gynecologist.
In the reception area, we told a nurse that we had worked in the hospital thirty years ago. We showed her a photo of the staff from 1980 and soon a small cluster of people formed around us to have a look. They recognized people, laughing delightedly and commenting on who had died and who had been good-looking in their youth. And to our enormous surprise and delight one of the nurses recognized one of our old assistant nurses, Mama Rosa, and called her on her mobile phone. That was how we later were able to meet some of our old co-workers and share a lunch together.
A nurse showed us round the antenatal clinic linked to the childcare center, where twenty proudly expectant women were sitting in the waiting room. All were nicely dressed. It is what pregnancy feels like in Africa—you are proud and pleased to be pregnant and to attend the social event that is a visit to the antenatal clinic.
What had been the outpatient reception in our time was now a specialized area for patients with HIV and AIDS. It was staffed by two nurses and a doctor. The doctor wore a crisp white coat and was seated at a glass-topped desk. When he heard that his post had been mine thirty years ago, we hugged.
That doctor was now responsible for primary care in the town. He gave me an overview of the pattern of disease. I listened in silence. Later, Agneta pointed out it was ages since I had shut up for an entire half hour.
He had given us a comprehensive understanding of how disease was distributed in his district. They still had problems with childhood infections, and the widespread availability of mosquito nets had not eliminated malaria cases. And, of course, there was pneumonia and diarrhea as well as victims of traffic accidents and other minor and major injuries.
“I assume it was just the same when you were here,” he said.
Agneta asked about the child and adolescent psychiatry services. Did they see much ADHD (attention deficit hyperactivity disorder)?
“Yes, we do. It’s tragic. We see them coming in for minor surgery.” The doctor sighed.
He told us that the new medicines for treating ADHD were too expensive, and psychologists seemed unable to help these children. Their diagnosis meant that they got into trouble—climbing on buildings and trees, hurting themselves falling off, or being beaten up. And then they came in to have wounds stitched.
The thoughtful doctor went on to tell us that he did not work shifts in the hospital as I had done. Also, another doctor was responsible for the rural catchment area. In the 1970s, that had been just another part of my job. His post carried about a third of the workload that mine had but, even so, his load was heavy. He also mentioned that he had hoped to buy a house on the coast but had been too late. The property prices had already risen so much that he could not afford to buy a site with a sea view.
As we left, I was full of admiration and deep respect.
The new hospital had been built a little farther away, high up above the town, on a spacious site with room for expansion. There was an ambulance driveway to an emergency entrance. The morning routine was like that of a Swedish hospital: before the visit to the wards, the day began with an X-ray session and a brief review of the emergency patients from the night.
Because of the infection risk, you were allowed to put your rucksack only on a chair and not on the floor. The delivery suite had a tiled floor that could be washed and to avoid dirt being brought in, the staff wore indoor shoes. These days, dehydrated children in Nacala were put on intravenous drips, just as my pediatrician friend had insisted should be the case thirty years earlier.
This Mozambique was not like the country we had lived in. This is not to say that everything was perfect—far from it. But everything had moved forward.
There were still extremely poor areas to the north of Nacala, where two junior medics worked alone, serving a large population. The size of their task became clear when we heard of the thirteen-year-old girl who had become pregnant. When she was about to give birth, the girl, whose pelvis was too narrow for childbirth, had become extremely ill. She had been transported to the hospital from her remote part of the district—a northern area from where, in my days, we saw no patients at all. On the way to Nacala, the crisis point was reached and her uterus burst. She not only lost the baby but had to have her torn uterus surgically removed, meaning she would never be able to have children. Agneta and I knew only too well what it means when a very young girl begins a home delivery and her body gives up. The message was clear: in some parts of the district, the poverty was no better than in our time, but here, in town, things had improved.
The staff was exceedingly curious and keen to talk with me. They were very aware that some aspects of the health service were still insufficient and hoped I would want to stay. Lack of specialization was one obstacle to continued development. There was a role for me, I felt—in my thirties, I had been the doctor who tried to learn from the nurses, but now, in my sixties, I could be useful by training specialists. The young doctors had been to medical school in the capital and had their degrees, but lacked the specialist skills you acquire during the years as a junior doctor under the guidance of senior and experienced specialists.
At my desk, then and now
The clinic, then and now
* * *
During my two years in Nacala in the late 1970s, I never diagnosed a case of type 1 diabetes. The patients all died before they saw a doctor. Now, the medics were having to learn to cope with such previously unseen diseases. During the ward round that evening, we witnessed the changing times in the shape of a twenty-one-year-old woman.
She was extremely thin, as anyone is with advanced, untreated diabetes. Her entire body language expressed alarm. As the ward-round staff stood talking to one another, she seemed to expect them to turn to her and tell her she would die.
Diabetes begins with frequent peeing and weight loss, followed by hyperventilation, loss of consciousness, and then death, unless insulin is given in time. The progression can be fast, sometimes as short as one week.
I tried to say something soothing, as one does when standing by a hospital bed. The Mozambican doctors stood to my left and right and I told them about her condition, as I myself had once been taught about treating diabetics by more experienced medics at Hudiksvall hospital back in 1975.
We spent that whole week in and around Nacala. It was moving to see again the colleagues from the two most intensive years of clinical practice of our lives. We noted the growth of the local economy but also the huge c
hallenges that still remained.
Mama Rosa, the assistant nurse from the maternity ward thirty years ago, arranged a lunch for us at a restaurant close to the marketplace. Papa Enrique, to whom I had once given my spare spectacles, was now almost blind and needed help with his food. His grandson had brought him on his motorbike. It was unclear whether Enrique recalled anything of his past life and it was difficult to talk with him as his hearing was not the best, but we did all we could to try to explain who we were. Seeing them all again made me almost tearful.
And now, at last, I had a chance to apologize to Ahmed.
Ahmed had been our hospital cleaner. I used to walk round inspecting the whole hospital, even the toilets. I lost my temper if anything looked dirty. Everywhere had to be clean.
One morning, the toilets were filthy, not even flushed properly. I was outraged and shouted: “Where is Ahmed?”
“He isn’t in yet,” someone said.
“What, not in yet? It’s quarter to nine already!”
“We don’t know what’s happened.”
“Can’t someone go and fetch him?”
“But maybe we should just wait—”
I interrupted, speaking more loudly: “Someone should go and get him here, now.”
An hour later, Ahmed stood outside my door, shaking.
“Senhor Doktor, I am very sorry that I’m late. My son died last night.”
My expression did not change. “Is that so? What did he die from?”
“Measles.”
“Why didn’t you see that he was vaccinated?”
Ahmed’s first-born son had died. His home had been taken over by the wake but there I was, telling him off for being late and then for not having had his child vaccinated. It was a dreadful moment to remember and also an indication of how much pressure I had been under, like everyone who worked there at the time.
Ahmed did not want to discuss that episode, and so the talk returned to everyday events and old anecdotes.
We drove past our old house and both felt very touched to see what was still stuck to the back door. There had been a break-in while we lived there and the thieves smashed the window in the kitchen door. I repaired it by nailing the lid of a wooden box sent from Sweden. Our family had packed it full of food from home. The address label on the lid read “To Doctor Hans Rosling, Nacala,” and the text was still visible thirty years later.
* * *
It was striking that those two years, which had meant so much to us, had mattered so little in Nacala. We left the town and were still shocked by the hopelessness of the apparently stagnant life in the most remote villages, where little or nothing had changed. At the same time, we had been encouraged by the inspiring young Mozambicans we had met.
On the last day of our return visit to Mozambique, we had been invited by a seventy-six-year-old lady to take afternoon tea. She had been born in the USA but had become a Mozambican citizen long ago. She shared with us her very realistic, factual take on her country’s development. Her views were based on a deep understanding of what building the nation of Mozambique had meant. Her name was Janet Mondlane.
Agneta and I had met Janet in Sweden in the autumn of 1968. She had been one of our very first guests for supper in our shared student apartment.
Janet was born in the 1930s in Illinois. At the age of seventeen, she attended a talk at the local church in Geneva, Wisconsin, given by Eduardo Mondlane, about the future of Africa. Eduardo had grown up in rural Mozambique and had just arrived to begin his university studies in the USA when he and Janet met. They married a couple of years later and had three children together before they moved to Dar es Salaam in Tanzania. Eduardo became the leader of FRELIMO, the Mozambican liberation movement, and organized its headquarters there in neighboring Tanzania. Unlike Europe’s other colonial powers, Portugal’s fascist regime had no intention of giving up its African colonies.
While in Tanzania, Janet Mondlane took on responsibility for running an education center to help Mozambicans in exile. She had come to Sweden to raise money for her project. I remember well how surprised Agneta and I had been by her conversation over dinner in 1968. She spoke like a true Mozambican, even though she had never set foot in the country. She impressed us, just as her husband had done when I met him a year or so earlier, with her ability to think ahead, beyond independence and far into the future. She was setting up courses for teachers who would one day educate the next generation of teachers in the independent Mozambique.
Eduardo was killed only a year later. After the 1975 day of independence, as the widow of the country’s first leader, Janet Mondlane moved to Maputo, its capital. We never met her while we were living there but now we were invited for tea. We had a friend in common, Julie Cliff, professor of epidemiology in Maputo. It was Julie who arranged for us to see Janet, forty-three years after we last met.
Her home was in a beautiful spot on the top of a hill in the center of the city. You could see the harbor entrance from her windows. Her first-floor flat was modest, though. We recognized her at once. Her smile was as charming as it had been so long ago.
“Welcome,” she said. “At last, I have a chance to return your invitation.”
After a quick tour of her home, when we were seated on her sofa, I simply had to ask her about the past: “Do you really remember having supper with us in 1968, in our tiny student apartment?”
She laughed happily and slapped her palms against her legs.
“I sure do! I don’t remember what we ate, but I remember you served the meal in the kitchen,” she said.
Agneta and I looked at each other, thinking the same thing: our guest had remembered the cultural oddity of serving dinner in the kitchen even though our sitting room had enough space for a formal dining table. Janet quickly read our thoughts and took our hands in hers.
“I also remember how young we all were, and how much at home I felt in your company. You were so interested in our struggle for independence,” she said. “But tell me: do you think Mozambique has changed since you were working here thirty years ago?”
She nodded agreement when I mentioned the greater number of doctors in Nacala, and she was even more pleased to hear Agneta speak about the new primary schools in most suburbs and villages, and how senior school classes had been added where there was only junior teaching before. We had both been delighted and impressed to see teenage boys and girls streaming into newly built school buildings painted in lovely colors.
Then we had to mention our despair at seeing the extreme poverty that still existed in the left-behind villages, and the tone became more subdued. We asked Janet about politics, governance and funding. Was aid money used in the best possible way to further economic growth? How corrupt were the community leaders really? And the question that Janet often had to deal with: if your husband were alive, would corruption be less extensive?
She was very composed and serious when she answered our questions, like a friend sharing something very important with us.
“Being head of state in one of Africa’s poorest countries is very difficult: possibly the toughest, most challenging job in the world. People are looking to you to meet many and varied needs—from those who live in extreme poverty to members of your own extended family. So many individuals depend on you. You have been helped by them through your life and now they expect you to reciprocate.
“Honestly, I can’t be sure how my husband would have turned out as president. Maybe neither better nor worse than the presidents that followed him. And I think our current one, Armando Guebuza, is doing well.”
Janet explained what she had observed as Mozambique was being built. The vision she and her husband had shared when they returned to Africa fifty years ago had now become reality. The former colony was now a relatively stable, independent country with elected presidents in lawful succession. The people were now much better educated. The university in the capital, named after Janet’s husband, not only trained teachers and other professionals but was dev
eloping its own areas of research specialization.
“It all takes time. Looking from outside, you tend to see our failures. There are still so many serious problems that obscure how far we have come,” she said. “What you say about Nacala fits with what I see—lots of progress but still so much more to do.”
Then she became very serious. She put down her cup of tea and cake to free her hands so that she could gesture to emphasize her message.
“Considering where Mozambique started, and how far we aim to go, thirty years is not a very long time.” Development must be allowed to take its time.
* * *
Some things, however, cannot wait. One case in point: a deadly virus able to cross oceans. My most terrifying and challenging job began in 2014, when ebola broke out in western Africa.
7
Ebola
Fear of ebola hit me hard one day in September 2014. That afternoon, I had spotted on Twitter an article about ebola, published in the New England Journal of Medicine, the USA’s most prestigious medical-research journal. The authors of the article were Chris Dye, Director of Strategy at the WHO, and his team.
Their research included a graph that made me freeze with dread: it showed a steep increase, week by week, in the number of new cases of ebola during the past month. The expected number of new cases for the weeks to come was also plotted on the graph. The spread of the epidemic would accelerate unless something drastic was done to stop the outbreak. I remember even reading some of the article out loud to myself.
The previous evening I had come home from making a presentation in Portugal and the following morning I was due to leave for Switzerland to make another. Despite this, I stayed up for a long time, absorbed by this crucial study. I had been aware of the ebola outbreak since February, when it was first mentioned in the news, and since August I had started to be seriously worried about the epidemic in western Africa. Yet during these past months, what I had felt was more a professional concern.
