How I Learned to Understand the World

by Hans Rosling

  Chris Dye’s research team had used ebola data from the start of the epidemic up to September 14 to calculate an estimate of the expected number of cases per day as far ahead as early November. It was the way the line representing their predictions curved ever more steeply upward that was so frightening: the number of new cases per day had doubled every third week until mid-September, and their analysis indicated that this would continue if the response to the epidemic was not fast and effective enough.

  Already by the beginning of September, people were dying in the streets of Monrovia, Liberia’s capital city, something that had not happened in modern times except during wartime or because of a natural disaster. So many people had fallen ill so quickly. The field medical facilities had soon run out of beds, and many patients never got treatment.

  That graph predicted what would happen if the number of new cases continued to double every third week. Nine weeks later, at the start of November, the number of new patients per day would be not twice as many, not four times as many, but eight times as many as now.

  If the cases increased at this rate, Monrovia, the place likely to be the most severely affected, would soon be paralyzed. The progression is called exponential growth or, if you prefer, explosive growth. The numbers suggested that, on average, each patient would infect two healthy individuals and each of them would become ill enough within a few weeks to infect two more, and so on. But it was not the figures in themselves that triggered my sense of fear, but imagining the situation in Monrovia in November, if this exponential growth of the disease continued unchecked. Liberia would sink into even greater chaos than during the recently ended civil war. Many would rush to leave the country. That would be catastrophic, because then the spread of the disease would become international and utterly unpredictable.

  These fears changed our priorities at Gapminder that year. What could we do to help? We produced informative videos explaining the threat. Our focus was on attempting to explain what would happen if the number of new cases doubled every third week. Our short films were viewed by millions in just a few days.

  The ebola outbreak had so far been almost totally confined to three small countries in West Africa: Guinea, Sierra Leone, and Liberia. Why then had fear of ebola grown so fast in Europe and North America during 2014? Because the deadly virus can be transported across borders and oceans inside a human body. Any infected individual who traveled elsewhere was liable to infect others wherever they ended up. The dread of the disease was, of course, heightened by the fact that there was still no effective treatment.

  Six months earlier, at the end of March 2014, I had taken note in passing that the WHO had announced the spread of ebola from Guinea to Liberia. Little did I know that six months later I would have a desk of my own in Liberia’s Ministry of Health in Monrovia and that I would be working as the “Deputy Director of ebola Surveillance.” If, in addition, someone had told me that, because of ebola, this would be the first year that I would not celebrate Christmas and New Year with my wife and my family, it would have sounded like a bad joke. As it happened I ended up celebrating an unforgettable Christmas that year in the company of Luke Bawo, my roommate and boss in Liberia. Just before I left Liberia, I was honored by being accorded traditional chieftain status and given the title “Chief Tanue.”

  It was only later in the autumn of 2014 that the reality dawned on me: I had to cancel or postpone all engagements and offer my services to the battle against ebola. Experts like me should have understood the extent of the danger earlier. Most of us took our time to grasp the urgency of the epidemic and so, too, did the rest of the world. The handful of expert epidemiologists and tropical-disease specialists who did see what was coming worked for the WHO and did not have the necessary kind of budget to take action.

  Why did we fail in this way? We had for some time been observing several outbreaks of ebola, all in faraway African countries. During the second half of 2013 and the spring of 2014, the virus had been on the move from the remote highlands of rural Guinea to equally isolated regions of Liberia and Sierra Leone, but the world did not care. None of the outbreaks had spread to capital cities—that is, the infection had never come close to sites of government or to international airports.

  Before long, though, there were cases in Conakry and Monrovia, the capitals of Guinea and Liberia respectively.

  Public health professionals, and that includes me, should have reacted more quickly when cases of ebola started to spread to large cities with extensive slums. I blame myself, particularly, because I am not just any professor in global health: for decades, my research focused on epidemics in remote parts of rural Africa. The insight that ebola had the potential to become a major global threat if the infection spread to a capital city with a large slum population and an international airport was one I had already shared with most scientists working in this field. And now it had actually happened.

  On August 8, 2014, the WHO declared that the ebola epidemic had become an acute danger to health on an international scale. Now, finally, everyone sat up and took notice. The alarm spread. Foreign investment stopped, at first leading to counterproductive measures such as flight cancelations and attempts to isolate the afflicted countries. Eventually, resources were diverted to control the disease in western Africa.

  The worldwide fear felt at the time was completely justified but it surfaced too late. By then, all we could do was make up for lost time.

  * * *

  It was October 10. We were in the government building in Stockholm. Eugene Bushayija looked straight at me. He was clearly very worried; “No one understands what should be done about the ebola outbreak in Monrovia,” he said.

  Eugene worked for Médecins Sans Frontières. We had just come to the end of a meeting with Swedish government officials and academics about what Sweden could contribute to stop the epidemic. Now, only the two of us were left in the meeting room and we found ourselves agreeing that nobody seemed to know exactly what was going on in western Africa.

  Eugene went on: “MSF treatment centers are admitting as many ill patients as they have the capacity to treat. The majority test positive for ebola. But we’re not running the only facilities and because MSF is independent of the government, we can no longer be sure of the overall picture. Still, our center in Monrovia alone registered more confirmed cases than are shown in this week’s WHO report.”

  I was very well aware that hard clinical work in field hospitals was unsuitable for someone of my age, but I felt there must be something I could do.

  * * *

  Ten days after the meeting in Stockholm, in late October 2014, I was at my new desk in Monrovia. I had brought a couple of suitcases full of everything I thought I might need: a laptop, a printer, a projector, spare memory sticks, and—not least—appropriate clothing. At first, Agneta had reservations. Did I really have to go? Was I desperate to prove to myself and others how brave I still was? We talked about my plan, and Agneta came to the conclusion that I probably could make a difference. I had her full support.

  I spent the time on the plane reading up on ebola. Before landing, I prepared to protect myself against exposure to infection. What would the airport be like? I ought to have brought disinfectant wipes to clean my suitcase, I thought, as my head filled with all the likely and unlikely routes of infection. A friendly woman from the Swedish embassy picked me up at the airport and drove me to the Grand Hotel, where the embassy had booked a room for me. Before entering the hotel, I was shown a disinfectant routine: I had to wash my hands in a bucket of chlorinated water. The bucket was on a stool and on the floor next to it was a plastic basin also with chlorinated water for me to step into with my shoes on.

  The hotel seemed to have been recently built. The lobby was an elegant space, with tall, freshly painted pale-yellow walls and pillars of dark-red stone supporting the high ceiling. To the right, I spotted an ATM and two small shops. The smiling receptionist handed me the key to a third-floor room.

  I hav
e never been so appreciative of a high-class, spotlessly clean hotel room as I was then. Yet the risks were still too great. I washed and cleaned myself as carefully as I have ever done, then I wiped all the wardrobe shelving with chlorhexidine-soaked wipes and obsessively placed my clothing in piles that did not touch the walls. Then I cleaned the desk and the outside of my suitcases with more disinfectant wipes. Finally, I went to bed, slept restlessly and dreamed I was running a fever. Fear of infection stayed with me throughout my time in Monrovia, but after a week or two these preparations had turned into a daily routine that I hardly noticed.

  During my first day in Monrovia, I was given an overview of the local response to the epidemic. Everywhere was full of frantic activity. Experts were crowded into small rooms with maps of Liberia on the walls. I was ushered in and out of tall office buildings, always stopping at the entrance for the compulsory washing of hands and shoes in chlorinated water. Introductions went easily at the American office run by the federal Centers for Disease Control and Prevention (CDC) because the staff recognized me from my TED talks. They were extremely keen to find out what I was doing in Liberia and surprised to learn that I had come to work for several months as an independent expert.

  Liberia’s Deputy Chief Medical Officer Tolbert Nyenswah also recognized me when we came across each other in one of the many corridors I wandered along that day. I gave him my Karolinska Institute card and explained that I had been investigating epidemics in poor African countries for almost twenty years, after first working as a district doctor in the public health service in Mozambique.

  “In other words, I do understand what shortage of resources can mean,” I added.

  He nodded, his expression a mixture of surprise and approval. There was no reason he should have known of my background before I went on the lecture circuit. I bent down to get a letter from my bag.

  “I have brought with me a letter to your president, Ellen Johnson Sirleaf. It is from the Royal Academy of Sciences in Stockholm. May I deliver it through you?”

  It had been beautifully handwritten on the academy’s thick correspondence paper. The permanent secretary, Staffan Normark, as a representative not only of the academy but also the entire international scientific establishment, was apologizing that research into ebola had not advanced further than it had at present.

  This had troubled me, too. We, a group of experts on international public health, had earlier compiled a list of seventeen diseases needing further research into treatment, and presented it to the pharmaceutical companies. Ebola was included in the list. Because the research has not been carried out, simple test methods, vaccines, and disease-specific medication were not available.

  Tolbert’s face was serious as he read the brief letter. Then he sighed a little, looked up at me with screwed-up eyes and, after a moment’s silence, said to me: “Thank you. We have never been addressed in these terms before. The president will appreciate this apology.”

  In another corridor I was introduced to Liberia’s ultra-efficient deputy minister of health. He told me: “Please join us tomorrow at the coordination meeting. It’s on the ground floor and starts at nine. I will introduce you to our own leaders of the disease response and also the experts from abroad. You are very welcome here.”

  My admiration and respect for Tolbert Nyenswah’s outstanding leadership ability, and the calm, thoughtful way in which he managed the entire response to the ebola outbreak, would continue to grow during the months I had the privilege of working under him.

  * * *

  Back in my cool, air-conditioned hotel room after my first day, I felt anxious about infection in my sweaty clothes. I wiped my bag down with paper napkins soaked in hand-cleaning alcohol. I stripped, wiped my belt with more napkins, and put all my clothes in the laundry basket. I showered. The whole cleansing process, which included paying extra careful attention to my nails, took more than half an hour. Wearing only a clean pair of underpants, I folded back the bedspread, blanket, and top sheet and lay down on the bed.

  Lying there, I reflected on my first day. It had worked out unexpectedly well but I felt doubtful nonetheless. Would I achieve what I had set out to do? I also felt a little ashamed about my ultra-intensive cleaning routine, but it had calmed me, too, and would become a soothing ritual that I carried out each day.

  I rested for a little longer and then took the elevator to the top-floor restaurant, had an excellent buffet dinner and rounded it off by sipping a Coca-Cola beneath the black, star-studded sky. The tropical night was warm up there on the roof terrace. A grant from the Wallenberg Foundations, which fund research deemed beneficial to Sweden, had made it possible for me to stay in the best hotel in Monrovia. I resolutely silenced my critical conscience but told myself sternly: “You shall have to make up for all this by working hard.” Back in my room, I fell asleep quickly, but was woken by a nightmare where I fell ill with fever and diarrhea.

  * * *

  “Why does the WHO report say that the current number of confirmed ebola cases in Monrovia is close to zero? It’s obviously not true!” I spoke frankly at the following morning’s meeting with the staff at the American CDC office.

  This had also not escaped Frank Mahoney, one of the world’s best, most experienced infection epidemiologists. It had infuriated him and he launched into a systematic account of what he thought were the reasons. Frank was short and a bit overweight, with a crew cut and unshaven chin. He wore an ill-fitting dark jacket with a limp tie. His colleague Joel Montgomery, also a very skilled infection epidemiologist, just as his shirt was a little whiter and his hair a fraction longer than Frank’s, spoke more calmly.

  Both men thought the problem stemmed somehow from the epidemic surveillance office at the Ministry of Health. Its head was a Liberian called Luke Bawo. Terry Lo, another American epidemiologist, cut into my questions and speculations: “I think you should go to the ministry and chat to him. He’s very easy to talk to. I’m working with his group there. Why don’t you come along with me after this meeting?”

  It was late morning when we set out, and the sun was flooding Monrovia with light. A quarter of an hour later, the car pulled up in front of the health ministry’s three-story building of yellowing concrete. Around the car park, filled mostly with white jeeps bearing the ministry’s logo, was a high wall of the same discolored concrete.

  Before we were allowed into its long corridors, guards at the entrance to the ministry kept watchful eyes on us to check that we followed the chlorinated-water sanitation regime. Terry Lo took me to his office, where people were hard at work at the four desks they had managed to squeeze into the room.

  “I’m managing the HISP database,” a middle-aged Irishman and WHO staffer said.

  “HISP? What is that?” I asked.

  They all stared at me, obviously baffled at my failure to recognize the acronym.

  “The Health Information System Data.”

  Just as I was about to start asking questions about the data-entry system, the door was pushed open. The newcomer stepped quickly inside. The swiftness of his movements was amazing because he had a gammy leg that he had to push forward with his hand. No one seemed to notice, though, and he was very much in control of his movements, suggesting that he had coped with his handicap for a long time.

  Terry gestured to catch his attention: “Professor Rosling, I’d like to introduce our boss, Luke Bawo.”

  Luke spoke in a broad, Liberian-accented English, and I had to strain to follow what soon became a lively conversation. Keen to find out what I was doing there, he asked me some straightforward questions. I said that I wanted very much to contribute to the ministry’s efforts to control ebola and added that I was fully financed to work in an independent capacity.

  “Trouble is, another desk will hardly fit in here,” I finally pointed out.

  That was easily dealt with. Quickly, Luke ushered me into the room next door and made a welcoming gesture. It had an air-conditioning unit, a small fridge, and two gre
en-painted metal desks with tops made of brown-speckled plastic. The larger of the two desks was stacked high with piles of paper, boxes and a printer. The smaller one was empty.

  Luke pointed at it: “That is your desk.”

  “Thank you,” I said, pleased and surprised. “And whose desk is that?” I asked, indicating the larger one.

  “It’s mine. You will be based in my room, as the deputy head of ebola surveillance. We can easily share the work between us here. You can have a key of your own, I have a spare. There’s room for your bag as well,” he said and pointed to a space behind my desk.

  He was not being bossy but spoke calmly and pleasantly as if all these things were perfectly natural. Then, his face and voice grew more serious.

  “We really need you in Liberia. Will this be all right for you?” he asked, looking deep into my eyes. I liked his unaffected, direct manner but felt quite startled: less than twenty minutes after walking through the front door, I had been offered an official post in the ministry. My thoughts flashed back over how smoothly everything had run, from the immediate reply to my inquiry about a UN secondment to the completion of my preparations in Sweden. I had ended up in the best hotel in town and had gained the best possible impression of the Liberian in charge of the battle against ebola.

  Since then, I have reflected on how quickly I made up my mind.

  “Yes, it’s great. But is it really this simple? Ought we not write an agreement and sign it, both of us?” I asked.

  “No need for that,” Luke said.

  Luke would go on to meet all my expectations of a good boss. We became very close friends and since I couldn’t spend that Christmas with my own family, I spent it with his. Within a few days, I had my business cards bearing the ministry logo and a little later I received a gift of several stunning, colorful West African shirts.