In 2016 on a trip to Europe, I made a special visit to Sweden to say good-bye to one of my heroes.
Hans Rosling, who died in 2017, was a trailblazing professor of international health who became famous for teaching experts facts they should already know. He became well known for his unforgettable TED Talks (more than 25 million views and counting); for his book Factfulness, written with his son and daughter-in-law, which shows us that the world is better than we think it is; and for their Gapminder Foundation, whose original work with data and graphics has helped people see the world as it is. For me personally, Hans was a wise mentor whose stories helped me see poverty through the eyes of the poor.
I want to tell you a story Hans shared with me that helped me see the impact of extreme poverty—and how empowering women can play the central role in ending it.
First, though, I should let you know that Hans Rosling was less taken with me than I was with him, at least at the start. In 2007, before we knew each other, he came to an event where I was going to speak. He was skeptical, he later told me. He was thinking, American billionaires giving away money will mess everything up! (He wasn’t wrong to be worried. More on that later.)
I won him over, he said, because in my remarks I didn’t talk about sitting back in Seattle reading data and developing theories. Instead, I tried to share what I’d learned from the midwives, nurses, and mothers I had met during my trips to Africa and South Asia. I told stories about women farmers who left their fields to walk for miles to a health clinic and endured a long, hot wait in line only to be told that contraceptives were out of stock. I talked about midwives who said their pay was low, their training slight, and they had no ambulances. I purposely didn’t go into these visits with fixed views; I tried to go with curiosity and a desire to learn. So did Hans, it turns out, and he started much earlier than I did and with greater intensity.
When Hans was a young doctor, he and his wife, Agneta—who was a distinguished healthcare professional in her own right—moved to Mozambique, where Hans practiced medicine in a poor region far from the capital. He was one of two doctors responsible for 300,000 people. They were all his patients, in his view, even if he never saw them—and usually he didn’t. His district had 15,000 births a year and more than 3,000 childhood deaths. Every day in his district, ten children died. Hans treated diarrhea, malaria, cholera, pneumonia, and problem births. When there are two doctors for 300,000 people, you treat everything.
This experience shaped who he was and defined what he taught me. After we met, Hans and I never attended the same event without getting time with each other, even if it was only a few minutes in the hallway between sessions. In our visits—some long, some short—he became my teacher. Hans not only helped me learn about extreme poverty; he helped me look back and better understand what I had already seen. “Extreme poverty produces diseases,” he said. “Evil forces hide there. It’s where Ebola starts. It’s where Boko Haram hides girls.” It took me a long time to learn what he knew, even when I had the advantage of learning it from him.
Nearly 750 million people are living in extreme poverty now, down from 1.85 billion people in 1990. According to the policymakers, people in extreme poverty are those living on the equivalent of $1.90 a day. But those numbers don’t capture the desperation of their lives. What extreme poverty really means is that no matter how hard you work, you’re trapped. You can’t get out. Your efforts barely matter. You’ve been left behind by those who could lift you up. That’s what Hans helped me understand.
Over the course of our friendship, he would always say, “Melinda, you have to be about the people on the margins.” So we tried together to see life through the eyes of the people we hoped to serve. I told him about my first foundation trip and how I came away with so much respect for the people I saw because I knew their daily reality would ruin me.
I had visited the slum of a large city, and what shocked me was not little kids coming up to the car and begging. I expected that. It was seeing little kids fending for themselves. It shouldn’t have surprised me; it’s the obvious consequence of poor mothers having no choice but to go off to work. It’s a matter of survival in the city. But whom do they leave the baby with? I saw children walking around with infants. I saw a 5-year-old running with his friends in the street, carrying a baby who was still in the wobbly-headed stage. I saw kids playing near electrical wires on a rooftop and running near sewage that was streaming down the edge of the street. I saw children playing near pots of boiling water where vendors were cooking the food they were selling. The danger was part of the kids’ day and part of their reality. It couldn’t be changed by a mother making a better choice—the mothers had no better choice to make. They had to work, and they were doing the best anyone could do in that situation to take care of their kids. I had so much regard for them, for their ability to keep on doing what they had to do to feed their children. I talked many times with Hans about what I saw, and I think it prompted him to tell me what he saw. The story Hans shared with me a few months before he died was, he told me, the one that he thought best captured the essence of poverty.
When Hans was a doctor in Mozambique in the early 1980s, there was a cholera epidemic in the district where he worked. Each day he would go out with his small staff in his health service jeep to find the people with cholera rather than wait for them to come to him.
One day they drove into a remote village at sunset. There were about fifty houses there, all made of mud blocks. The people had cassava fields and some cashew nut trees but no donkeys, cows, or horses—and no transportation to get their produce to market.
As Hans’s team arrived, a crowd peered inside his jeep and began saying, “Doutor Comprido, Doutor Comprido,” which in Portuguese means “Doctor Tall, Doctor Tall.” That’s how Hans was known—never “Doctor Rosling” or “Doctor Hans,” just “Doctor Tall.” Most of the villagers had never seen him before, but they had heard of him. Now Doctor Tall had come to their village, and as he got out of the car, he asked the village leaders, “Fala português?” Do you speak Portuguese? “Poco, poco,” they answered. A little. “Bem vindo, Doutor Comprido.” Welcome, Doctor Tall.
So Hans asked, “How do you know me?”
“Oh, you are very well known in this village.”
“But I’ve never been here before.”
“No, you’ve never been here. That’s why we are so happy you’ve come. We are very happy.” Others joined in: “He is welcome, he is welcome, Doctor Tall.”
More and more people gathered, joining the crowd softly. Soon there were fifty people around, smiling and looking at Doctor Tall.
“But there are very few people from this village who come to my hospital,” Hans said.
“No, we very seldom go to hospital.”
“So how come you know me?”
“Oh, you are respected. You are so respected.”
“I am respected? But I’ve never been here.”
“No, you’ve never been here. And yes, very few go to your hospital, but one woman came to your hospital, and you treated her. So you are very respected.”
“Ah! One woman from this village?”
“Yes, one of our women.”
“Why did she come?”
“Problem with childbirth.”
“So she came to be treated?”
“Yes, and you are so respected because you treated her.”
Hans started feeling a bit of pride, and asked, “Can I see her?”
“No,” everyone said. “No, you cannot see her.”
“Why not? Where is she?”
“She’s dead.”
“Oh, I’m sorry. She died?”
“Yes, she died when you treated her.”
“You said this woman had a problem giving birth?”
“Yes.”
“And who took her to the hospital?”
“Her brothers.”
“And she came to the hospital?”
“Yes.”
“And I treated her?”
“Yes.”
“And then she died?”
“Yes, she died on the table where you treated her.”
Hans began to get nervous. Did they think he’d blundered? Were they about to unleash their grief on him? He glanced to see if his driver was in the car so he could make a getaway. He saw it was impossible to run so he began to talk slowly and softly.
“So, what illness did the woman have? I don’t remember her.”
“Oh, you must remember her, you must remember her, because the arm of the child came out. The midwife tried to drag the child out by the arm, but it was impossible.”
(This, Hans explained to me, is called an arm presentation. It blocks the chance of getting the child out because of the position of the baby’s head.)
At that point, Hans remembered everything. The child was dead when they arrived. He had to remove the child to save the life of the mother. A C-section was never an option; Hans didn’t have the setting for surgery. So he attempted a fetotomy (bringing out the dead infant in pieces), and the uterus ruptured and the mother bled to death on the operating table. Hans couldn’t stop it.
“Yes, it was very sad,” Hans said. “Very sad. I tried to save her by cutting off the baby’s arm.”
“Yes, you cut off the arm.”
“Yes, I cut off the arm. I tried to take the body out in pieces.”
“Yes, you tried to take it out in pieces. That’s what you told the brothers.”
“I’m very, very sorry that she died.”
“Yes, so are we. We are very sorry, she was a good woman,” they said.
Hans exchanged courtesies with them, and when there wasn’t much else to say, he asked—because he is curious and courageous—“But how can I be respected when I didn’t save the woman’s life?”
“Oh, we knew it was difficult. We know that most women who have the arm coming out will die. We knew that it was difficult.”
“But why did you respect me?”
“Because of what you did afterward.”
“What was that?”
“You went out of the room into your yard. You stopped the vaccination car from leaving. You ran to catch up with it, you made the car come back, you took out boxes from the car, and you arranged for the woman from our village to be wrapped in a white sheet. You provided the sheet, and you even provided a small sheet for the pieces of the baby. Then you arranged for the woman’s body to be put into that jeep, and you made one of your staff get out so there would be room for the brothers to go with her. So after that tragedy, she was back home the same day while the sun was still shining. We had the funeral that evening, and her whole family, everyone was here. We never expected anyone to show such respect for us poor farmers here in the forest. You are deeply respected for what you do. Thank you very much. You will always be in our memory.”
Hans paused here in the story and told me, “I wasn’t the one who did that. It was Mama Rosa.”
Mama Rosa was a Catholic nun who worked with Hans. She had told him, “Before you do a fetotomy, get permission from the family. Don’t cut a baby before you have their permission. Afterward, they will ask you only for one thing, to get the parts of the child. And you will say, ‘Yes, you will get the parts, and you will be given the cloth for the child.’ That’s the way. They don’t want anybody else to have parts of their baby. They want to see all the pieces.”
So Hans explained, “When this woman died, I was sobbing, and Mama Rosa put her arm around me and said, ‘This woman was from a very remote village. We must take her home. Otherwise no one will come to the hospital from that village for the next decade.’
“‘But how can we take her?’
“‘Run out and stop the vaccine car,’ Mama Rosa told me. ‘Run out and stop the vaccine car.’”
And Hans did it. “Mama Rosa knew what people’s realities were,” he said. “I never would have known to do that. Often in life, it’s the older males who get credit for the work that young people and women do. It isn’t right, but that’s how it works.”
That was Hans’s deepest witness of extreme poverty. It wasn’t living on a dollar a day. It was taking days to get to the hospital when you’re dying. It was respecting a doctor not for saving a life but for returning a dead body to the village.
If this mother had lived in a prosperous community and not on the margins among farmers in a remote forest in Mozambique, she never would have lost her baby. She never would have lost her life.
This is the meaning of poverty I’ve come to see in my work, and I see it also in Hans’s story: Poverty is not being able to protect your family. Poverty is not being able to save your children when mothers with more money could. And because the strongest instinct of a mother is to protect her children, poverty is the most disempowering force on earth.
It follows that if you want to attack poverty and if you want to empower women, you can do both with one approach: Help mothers protect their children. That is how Bill and I began our philanthropic work. We didn’t put it in those words at the time. It just struck us as the most unjust thing in the world for children to die because their parents are poor.
In late 1999, in our first global initiative, we joined with countries and organizations to save the lives of children under 5. A huge part of the campaign was expanding worldwide coverage for a basic package of vaccines, which had helped cut the number of childhood deaths in half since 1990, from 12 million a year to 6 million.
Unfortunately, the survival rate of newborns—babies in the first twenty-eight days of life—has not improved at the same pace. Of all the deaths of children under 5, nearly half come in the first month. And of all the deaths in the first month, the greatest number come on the first day. These babies are born to the poorest of the poor—many in places far beyond the reach of hospitals. How can you save millions of babies when their families are spread out in remote areas and follow centuries of tradition when it comes to childbirth?
We didn’t know. But if we wanted to do the most good, we had to go where there’s the most harm—so we explored ways to save the lives of mothers and newborn babies. The most common factor in maternal and infant death is the lack of skilled providers. Forty million women a year give birth without assistance. We found that the best response—at least the best response we have the know-how to deliver now—is to train and deploy more skilled healthcare providers to be present for mothers at birth and in the hours and days after.
In 2003, we funded the work of Vishwajeet Kumar, a medical doctor with advanced training from Johns Hopkins who was launching a life-saving program in a village called Shivgarh in Uttar Pradesh, one of India’s poorest states.
In the midst of this project, Vishwajeet married a woman named Aarti Singh. Aarti was an expert in bioinformatics—and began applying her expertise to designing and evaluating programs for mothers and newborns. She became an indispensable member of the organization, which was named Saksham, or “empowerment,” by the people in the village.
Vishwajeet and the Saksham team had studied births in poor rural parts of India and saw that there were many common practices that were high risk for the baby. They believed that many newborn deaths could be prevented with practices that cost little or nothing and could be done by the community: immediate breastfeeding, keeping the baby warm, cutting the cord with sterilized tools. It was just a matter of changing behavior. With grants from USAID and Save the Children and our foundation—and by teaching safe newborn practices to community health workers—Saksham cut newborn mortality in half in eighteen months.
At the time of my 2010 visit to Shivgarh, there were still 3 million newborn deaths in the world every year. Nearly 10 percent of those deaths occurred in Uttar Pradesh, which has been called the global epicenter of newborn and maternal deaths. If you wanted to bring down the number of newborn deaths, Uttar Pradesh was an important place to work.
On the first day of my trip, I met with about a hundred people from the village to talk about newborn care. It was a large crowd, with mothers seated at the front and men toward the back. But it felt intimate. We were sitting on rugs laid out under the shade of a large tree, packed in tightly to make sure no one was left out in the blistering sun. After the meeting, we were greeted by a family with a little boy about 6 years old. Seconds later, Gary Darmstadt, who was our foundation’s head of maternal and newborn health at the time, whispered to me, “That was him; that was the baby!” I looked back and saw the 6-year-old boy and said, “What baby? That’s not a baby.” “That’s the one Ruchi saved,” he said. “Oh my gosh!” I said. “That’s the baby you told me about!?”
That 6-year-old boy had become lore. He was born in the first month of the Saksham program when the community health workers had just been trained, community skepticism was high, and everyone was watching. The baby, whom I had just seen as a healthy 6-year-old, was born in the middle of the night. The mother, in her first pregnancy, was exhausted and fainted during childbirth.
As soon as the sun came up, the recently trained community health worker was notified of the birth and came immediately. Her name was Ruchi. She was about 20 years old and came from a high-caste Indian family. When she arrived, she found the mother still unconscious and the baby cold. Ruchi asked what was going on, and none of the family members in the room said a thing. They were all terrified.
Ruchi stoked the fire to warm the room, then got blankets and wrapped the baby. She took the baby’s temperature—because she was trained to know that hypothermia can kill babies or be a sign of infection. The infant was extremely cold, about 94 degrees. So Ruchi tried the conventional things she’d done in the past, and nothing worked. The baby was turning blue. He was listless, and Ruchi realized that he would die unless she did something right away.
One of the life-saving practices Ruchi had learned was skin-to-skin care: holding a baby against the mother’s skin to transfer warmth from the mom to the newborn. The technique prevents hypothermia. It promotes breastfeeding. It protects from infection. It is one of the most powerful interventions we know of for saving babies.
Ruchi asked the baby’s aunt to give the infant skin-to-skin care, but the aunt refused. She was afraid that the evil spirit she thought was gripping the baby would take her over as well.
Ruchi then faced a choice: Would she give the baby skin-to-skin care herself? The decision wasn’t easy; doing something so intimate with a low-caste infant could bring ridicule from her own relatives. And this was a foreign practice in the community. If it didn’t go well, the family could blame her for the death of the baby.
But when she saw the baby getting colder, she opened up her sari and placed the newborn against her bare skin, with the baby’s head nestled between her breasts and a cloth covering both her head and the baby’s for modesty and warmth. Ruchi held the baby that way for a couple of minutes. His skin color appeared to be changing back to pink. She took out her thermometer and tested the baby’s temperature. A little better. She held the baby a few minutes more and took his temperature again. A little bit higher. Every woman there leaned in and watched as the baby’s temperature rose. A few minutes later, the baby started to move; then he came alive; then he started to cry. The baby was fine. He wasn’t infected. He was just a healthy baby who needed to be warmed and hugged.
When the mother regained consciousness, Ruchi told her what had happened and guided her in skin-to-skin care, then helped her initiate breastfeeding. Ruchi stayed another hour or so, watching the mother and baby in skin-to-skin position, and then she left the home.
This story spread like lightning through the nearby villages. Overnight, women went from saying “We’re not sure about this practice” to “I want to do this for my baby.” It was a turning point in the project. You don’t get behavior change unless a new practice is transparent, works well, and gets people talking—and Ruchi’s revival of this one-day-old baby had everybody talking. This was a practice all women could do. Mothers became seen as life-savers. It was immensely empowering and transformative.
I learned a lot from my trip to Shivgarh, and the most striking lesson for me—and what made it a departure from a lot of our prior work—is that it wasn’t about technological advances. Our emphasis at the foundation has always been on scientific research to develop life-saving breakthroughs like vaccines. We call this product development, and it continues to be our main contribution. But Vishwajeet and Aarti’s program for mothers and newborns showed me how much can be achieved by sharing simple practices that are widely known throughout the world. This taught me in a profound way that you have to understand human needs in order to effectively deliver services and solutions to people. Delivery systems matter.
What do I mean by a “delivery system”? Getting tools to people who need them in ways that encourage people to use them—that is a delivery system. It is crucial, and it is often complex. It can require getting around barriers of poverty, distance, ignorance, doubt, stigma, and religious and gender bias. It means listening to people, learning what they want, what they’re doing, what they believe, and what barriers they face. It means paying attention to how people live their lives. That’s what you need to do if you have a life-saving tool or technique you want to deliver to people.
Before launching the program, Saksham hired a local team of top students who spent six months working with the community to understand their existing practices and beliefs around childbirth. Vishwajeet told me, “Their cup is not empty; you can’t just pour your ideas into it. Their cup is already full, so you have to understand what is in their cup.” If you don’t understand the meaning and beliefs behind a community’s practices, you won’t present your idea in the context of their values and concerns, and people won’t hear you.
Historically, the mothers in the community would go to the Brahmin, a member of the priestly caste, and ask when to start breastfeeding, and he would say, “You can’t let down milk for three days, so you should start after three days.” False information is disempowering. Mothers would heed the advice of the Brahmin, and for the first three days of the newborn’s life, they would give the baby water—which was often polluted. Vishwajeet and Aarti’s team had prepared for this moment. They gently questioned traditional practices by pointing to patterns in nature that were part of the villagers’ way of life. They cited the example of a calf and its mother. “When we try to milk a cow and it doesn’t express milk, we make the calf suckle her to get the milk to let down, so why don’t you try the same and keep the baby against your breast to express milk.”
The villagers still said, “No, this isn’t going to work.” So the local team went to a few people in the community who had courage and influence and tried to persuade them. Team members knew that if they could create a culture of support around a young mother, the mother would be much more likely to try the new practice. When a few mothers tried it and were able to breastfeed right away, they said, “Wait a minute; we didn’t realize we could do this!” Then things took off; the community began to try the other health practices as well.
It’s a delicate thing to initiate change in a traditional culture. It has to be done with the utmost care and respect. Transparency is crucial. Grievances must be heard. Failures must be acknowledged. Local people have to lead. Shared goals have to be emphasized. Messages have to appeal to people’s experience. The practice has to work clearly and quickly, and it’s important to emphasize the science. If love were enough to save a life, no mother would ever bury her baby—we need the science as well. But the way you deliver the science is just as important as the science itself.
When I returned to the foundation after my trip to Shivgarh, I talked to our staff about delivery and cultural awareness and how crucial they are to saving lives. I said we have to keep working on innovation in products, in science and technology, but we have to work with the same passion on innovation in delivery systems as well. Both are indispensable.
Let me illustrate with an example that is personal to me, and one I haven’t shared before. It’s about my mom’s older sister Myra.
My aunt Myra is very dear to me. I called her “my other mother” when I was growing up. When she used to visit us, she would spend time coloring and playing board games with my sister, Susan, and me. We also went shopping a lot. She was so energetic and upbeat that it didn’t ever figure in my image of Aunt Myra that she didn’t have the use of her legs.
When my mom and Myra were young girls in the 1940s, they were playing at their great-uncle’s house, and afterward he told my grandmother, “Myra was sure being lazy today. She wanted me to carry her home.”
That night Myra woke up screaming in pain. My grandparents took her to the hospital, and a team of doctors figured out she had polio. They wrapped her legs up with gauze, boiled water, and put on hot packs. Doctors thought the heat would help, but it didn’t make any difference. Three or four days later, her legs were paralyzed. She was in the hospital for sixteen months, and my grandparents were allowed to visit her only on Sundays. Meanwhile, none of the kids in the neighborhood would play with my mom anymore. Everyone was terrified of the polio virus.
In the 1940s, the great polio challenge was product development, namely, finding a vaccine. Delivery didn’t matter. There was nothing to deliver. It wasn’t a question of privilege or poverty. The scientific innovation hadn’t happened yet. There was no protection for anyone against polio.
As soon as Jonas Salk developed his polio vaccine in 1953, the passionate effort to protect people from polio shifted from product development to delivery, and in this case, poverty did matter. People in wealthy countries were vaccinated quickly. By the late 1970s, polio had been eliminated in the US, but it continued to plague much of the world, including India, where the vast landscapes and large population made polio especially hard to fight. In 2011, defying most expert predictions, India became polio free. It was one of the greatest accomplishments in global health, and India did it with an army of more than 2 million vaccinators who traversed the entire country to find and vaccinate every child.
In March of 2011, Bill and I met a young mother and her family in a small village in Bihar, one of the most rural states in India. They were migrant workers, desperately poor, and working at a brick kiln. We asked her if her children had been vaccinated for polio, and she went into her hut and returned with an immunization card with the names of her children and the dates they received the vaccine. The vaccinators had not just found her children once. They had done so several times. We were awestruck. That is how India became polio free—through massive, heroic, original, and ingenious delivery.
Meeting people who deliver life-saving support to others is one of the highlights of my work. A few years ago on a trip to Indonesia, I met a woman named Ati Pujiastuti. As a young woman, Ati had enrolled in a government program called Midwife in Every Village that trained 60,000 midwives. She completed the program when she was just 19 years old and was assigned to work in a rural mountain village.
When she arrived in the village, she wasn’t welcome. People were hostile and distrustful of outsiders, especially young women with ideas for how to make things better. Somehow, this young woman had the wisdom of a village elder. She went door-to-door to introduce herself to everyone. She showed up at every community event. She bought the local newspaper and read it aloud to anyone who couldn’t read. When the village got electricity, she scraped up the money to buy a tiny TV and invited everyone to come watch with her.
Still, nobody wanted her services until, by pure accident, a pregnant woman who was visiting the village from Jakarta went into labor and asked Ati to deliver her baby. The birth went well, the villagers began to trust Ati, and soon every family wanted her present when mothers gave birth. She made sure that she was there, every time, even at the risk of her own life. Once she lost her footing while crossing a river and had to cling to a rock until help came. Another time she slipped on a muddy mountain path next to the edge of a cliff. Several times, she was thrown off her motorbike while riding on unpaved roads. Still, she stayed on and kept delivering babies. She knew she was saving lives.
As much as we need women on the ground delivering these services, we also need women in high places with vision and power. One of those women is Dr. Agnes Binagwaho, the former health minister of Rwanda.
In 2014, Agnes and I coauthored a piece in The Lancet. We called attention to the newborn lives that could be saved if the world could remedy one harsh reality: Most women in low-income countries give birth at home without a skilled attendant.
Putting a skilled birth attendant at the side of every mother in labor has been one of the great causes of Agnes’s life.
It’s not a cause anyone would have predicted twenty-five years ago. Agnes was working as a pediatrician in France in 1994 when she began hearing frightening news reports from home. Members of the majority ethnic group, the Hutus, had begun slaughtering minority Tutsis. She followed the horror from afar as almost a million people were murdered in a hundred days. Half of her husband’s family was killed.
Agnes hadn’t lived in Rwanda since she was 3 years old, when her father moved the family to France so he could go to medical school. But after the genocide, she and her husband decided to return to their country and help rebuild.
Returning to Rwanda was a shock, especially for a medical doctor who practiced in Europe. Even before the genocide, Rwanda was one of the worst places in the world to give birth, and the conflict made the situation far worse. Almost all the nation’s health workers had either fled or been killed, and wealthy nations weren’t giving health aid. A week after she arrived, Agnes nearly left. But her heart was breaking for those who couldn’t leave—so she stayed, became the longest-serving health minister in her country’s history, and spent the next two decades helping to build a new health system for Rwanda.
Under Agnes, the health ministry started a program where each Rwandan village (with about 300 to 450 residents) elects three community health workers—one dedicated solely to maternal health.
These and other changes have been dramatically successful. Since the genocide, Rwanda has made more progress in making birth safer than almost any other nation in the world. Newborn mortality is down by 64 percent. Maternal mortality is down by 77 percent. A generation after Rwanda was considered a lost cause, its health system is studied as a model. Agnes is now working with Dr. Paul Farmer, one of my heroes for bringing healthcare to poor people, first in Haiti and then around the world. Partners in Health, which Paul cofounded, has launched a new health sciences university in Rwanda, the University of Global Health Equity. Agnes is vice-chancellor of the university and is promoting fresh research into what makes delivery work.
What inspires me most about Agnes’s work in Rwanda, Ati’s work in Indonesia, and Vishwajeet and Aarti’s work in India is that they all show how a passionate emphasis on delivering services can ease the effects of poverty. This underscores the value of Hans Rosling’s stories about extreme poverty: When you begin to understand the daily lives of the poor, it does more than give you the desire to help; it can often show you how.
When people are not getting healthcare that most others get, the problem is by definition one of delivery. Medicine, services, and skilled assistance are not reaching them. That’s what it means to be poor. They’re on the margins. They’re not getting the benefit of what human beings know how to do for each other. So we have to invent a way of getting it to them. This is what it means to fight the effects of poverty. It’s unglamorous from a technological standpoint, but deeply satisfying from a human viewpoint—innovation driven by the feeling that science should serve everyone. No one should be excluded.
That is a lesson I have kept close to my heart: Poverty is created by barriers; we have to get around or break down those barriers to deliver solutions. But that’s not all. The more I saw our work in the field, the more I realized that delivery needs to shape strategy. The challenge of delivery reveals the causes of poverty. You learn why people are poor. You don’t have to guess what the barriers are. As soon as you try to deliver help, you run into them.
When a mother can’t get what she needs to protect her children, it’s not just that she’s poor. It’s something more precise. She doesn’t have access to a skilled birth attendant with the latest knowledge and crucial health tools. Why? There could be many reasons. She doesn’t have information. She doesn’t have money. She lives far from town. Her husband is opposed to it. Her mother-in-law doubts it. She doesn’t think she can ask for it. Her culture frowns on it. When you know why a mother can’t get what she needs, you can figure out what to do.
If the barrier is distance, money, knowledge, or stigma, we have to offer tools and information that are closer, cheaper, and less tainted by stigma. To fight poverty, we have to see and study the barriers and figure out if they’re cultural, or social, or economic, or geographic, or political, and then go around them or through them so the poor aren’t cut off from benefits others enjoy.
As soon as we began to spend more time understanding how people live their lives, we saw that so many of the barriers to advancement—and so many of the causes of isolation—can be traced to the limits put on the lives of women.
In societies of deep poverty, women are pushed to the margins. Women are outsiders. That’s not a coincidence. When any community pushes any group out, especially its women, it’s creating a crisis that can only be reversed by bringing the outsiders back in. This is the core remedy for poverty and almost any social ill—including the excluded, going to the margins of society and bringing everybody back in.
Back when I was in elementary school, there were two girls who sat at the back of the class, smart girls, but quiet and a little socially awkward. And there were two other girls, socially confident and popular, who sat toward the front of the class. The popular girls in front picked on the quiet girls in the back. I’m not talking about once a week. It was constant.
They were careful to do it when the teacher couldn’t see or hear—so no one did anything to stop them. And the quiet girls just got quieter. They were afraid to look up and make eye contact because it would bring on more abuse. They suffered terribly, and the pain never went away even after the bullying stopped. Decades later, at a class reunion, one of the popular girls apologized, and one of the girls who was bullied answered, “It’s about time you said something.”
All of us have seen something like this. And we all had a role in it. Either we were bullies, or we were victims, or we saw bullying and didn’t stop it. I was in that last group. I saw everything I just described. And I didn’t stop it because I was afraid that if I spoke up, the bullies would turn on me too. I wish I had known how to find my voice and help the other girls find theirs.
As I grew up, I thought abuse like that would happen less and less. But I was wrong. Adults try to create outsiders, too. In fact, we get better at it. And most of us fall into one of the same three groups: the people who try to create outsiders, the people who are made to feel like outsiders, and the people who stand by and don’t stop it.
Anyone can be made to feel like an outsider. It’s up to the people who have the power to exclude. Often it’s on the basis of race. Depending on a culture’s fears and biases, Jews can be treated as outsiders. Muslims can be treated as outsiders. Christians can be treated as outsiders. The poor are always outsiders. The sick are often outsiders. People with disabilities can be treated as outsiders. Members of the LGBTQ community can be treated as outsiders. Immigrants are almost always outsiders. And in most every society, women can be made to feel like outsiders—even in their own homes.
Overcoming the need to create outsiders is our greatest challenge as human beings. It is the key to ending deep inequality. We stigmatize and send to the margins people who trigger in us the feelings we want to avoid. This is why there are so many old and weak and sick and poor people on the margins of society. We tend to push out the people who have qualities we’re most afraid we will find in ourselves—and sometimes we falsely ascribe qualities we disown to certain groups, then push those groups out as a way of denying those traits in ourselves. This is what drives dominant groups to push different racial and religious groups to the margins.
And we’re often not honest about what’s happening. If we’re on the inside and see someone on the outside, we often say to ourselves, “I’m not in that situation because I’m different.” But that’s just pride talking. We could easily be that person. We have all things inside us. We just don’t like to confess what we have in common with outsiders because it’s too humbling. It suggests that maybe success and failure aren’t entirely fair. And if you know you got the better deal, then you have to be humble, and it hurts to give up your sense of superiority and say, “I’m no better than others.” So instead we invent excuses for our need to exclude. We say it’s about merit or tradition when it’s really just protecting our privilege and our pride.
In Hans’s story, the mother from the forest lost her life because she was an outsider. She lost her baby because she was an outsider. And her family had a warm memory of the doctor who returned their bodies to the village because they were outsiders. They were not used to being treated with respect. That is why they suffered so much death.
Saving lives starts with bringing everyone in. Our societies will be healthiest when they have no outsiders. We should strive for that. We have to keep working to reduce poverty and disease. We have to help outsiders resist the power of people who want to keep them out. But we have to do our inner work as well: We have to wake up to the ways we exclude. We have to open our arms and our hearts to the people we’ve pushed to the margins. It’s not enough to help outsiders fight their way in—the real triumph will come when we no longer push anyone out.