5
From Research to Teaching
The roll call had been done. My first lecture was due to begin. During the lunch break, I had smuggled the small blanket into a drawer in the teacher’s desk. No one knew it was there.
My job was to tell around thirty trainee doctors and nurses what it is like to provide healthcare in the least developed parts of the world. Many had already signed contracts for posts in distant, extremely poor places. I was meant to explain how they should go about their jobs.
That moment, just before the first lecture, was magic. I had never seen such eager and motivated students. They were a little shy of each other, though. Some had chosen this line of work because they were members of the Pentecostal Church, others came from charities with roles in Africa. When we polled the students’ voting preferences, the majority of the recruits to the course were either Christian Democrats or left-of-center Social Democrats. Even their dress style provided clues: some had their hair nicely done and wore clean, buttoned-up shirts and blouses, and others slouched in unwashed jeans. But they all showed an intense interest in hearing what I had to say.
“I’m going to introduce this course by telling you an anecdote that I heard from the minister of health in Mozambique,” I started, as I pulled the piece of material out from its hiding place. When I was working there as a doctor, I had to struggle with very limited resources. The minister’s story was about a very small blanket.”
In lectures, timing is all.
“Though the story is really about a man,” I went on, pointing at myself. “He was walking in the Mozambican mountains when night fell. He was sleepy but it was cold and all he carried with him was a small blanket. How to make the best use of it?”
At this point, I lay down flat on my back on top of the desk. Some of the students burst out laughing at the weirdness of my behavior. Others looked deadly earnest and a little uncomfortable. All were clearly thrown off balance a little. That was a good thing. I had caught their attention. I scanned the audience.
“I had better wrap the blanket round my feet, the man thought.” I put the tiny blanket on my feet. “But then his body became very cold. So instead he put the blanket across his belly.” I moved the piece of material to my hips.
“But now both his hands and his feet were freezing. He curled up but it didn’t help. He had the idea to wrap the blanket like a turban around his head. That didn’t work either. He still couldn’t sleep and it made him angry because he was so tired. ‘It must be possible to make the blanket bigger,’ the man thought.”
Now I stood up on the desk, put my foot on one end of the blanket and pulled energetically at the other end.
“I need to make it bigger!” I shouted. And I tore it in half.
The students laughed but were still at a loss to understand what I was really trying to tell them. Immediately, I began to explain.
“Don’t react like this man when you work in faraway healthcare systems. Don’t push your staff beyond what is reasonable and don’t imagine you can offer treatments like those available in Sweden. You must be wise and use ‘your blanket’ the right way. And don’t wear yourselves out. You have to stay in one piece, at least for the duration of the contract. How best to use limited resources in situations of great need is precisely what this course is about.”
Goofing around with the blanket was therapeutic for me. I had lived with a great deal of frustration during my years in Mozambique. When I got back to Sweden, I wound up teaching this class from 1983 to 1996. It was the very same course that Agneta and I had attended all those years back, before setting out for Nacala: Healthcare in Underdeveloped Countries. I took on the job because it was easy to combine with my annual field research in Mozambique. Between teaching periods, I could take the research months off with full pay on the condition that I also worked as a consultant to aid organizations. Gradually, my identity changed and I never went back to practicing medicine. I had turned into a scientist and an academic teacher in global healthcare.
The course was divided into three parts. One third was devoted to the care of mothers and children. One third dealt with viral infections in places of extreme poverty. The remaining third concentrated on how to organize and lead a healthcare system that has to function with perhaps as little as 1 percent of the resources available in Sweden. The students were exceptionally motivated: they had all signed on for specific healthcare jobs in some of the most impoverished countries in the world, generally for two years. The first two parts of the course suited them perfectly because the course content was all about how to treat patients.
The third part was more challenging. Everyone easily grasped the importance of learning about malaria and parasitic infections but most were surprised at being asked to learn how to estimate numbers of required staff, or figure out rates for fuel consumption, or draw up an annual budget for a mobile vaccination team. When, at the end of the course, the students were asked to evaluate it, many commented that learning more about laboratory test methods would have been preferable. But after they had been out in the field and were again presented with an evaluation form, the majority said they would have liked to know more about management, staff training, and budgeting. That was why it was such a help in my lectures to draw on the experiences of students who had already worked in low-income countries.
Most of these students had worked for religious missions and learned ineffective methods for recording how their services reached the population, whether it was support for pregnant mothers and maternity care, or the treatment of children with malaria, or injured patients requiring surgery. They had been taught to record how far the patients had traveled to reach the field hospitals or mission clinics, to gauge the effectiveness of the services being offered. When Médecins Sans Frontières (Doctors Without Borders) began their work, it turned out that their staff were also using the same old “How far did the patient travel?” question to determine how well they were serving their populations.
This method takes no account of population demographics.
I taught my students a different, three-stage approach to estimating how healthcare was used by people in the area.
First, get as correct a figure as possible for the number of people who live in the area you serve. Remarkably few of those who had experience of work in distant places had bothered to find this out, despite the facts that all countries conduct a census of some kind and that hospitals usually have defined catchment areas.
Second, get an estimate of how many children are born annually in this catchment area. In poor agricultural regions, the number of children born in a year is approximately 4.5 percent of the population. So, if the region has a population of 100,000, the expected number of newborns is 4,500.
Last, find out what proportion of the children were born with help from healthcare staff. You get this figure by dividing the number of registered births, let’s say 1,100 in a year, by the number of expected births (4,500 in this example). The conclusion in this case is that only about a quarter of all births were supported by trained staff and that the other three-quarters of births took place at home with no known skilled assistance.
Looking at vaccinations, if say 2,200 children are vaccinated against measles in one year and you compare that figure with the expected number of new births (4,500 in this example), you soon realize that half the area’s children are not getting vaccinated.
Ex cathedra: perched on the desk
These are the important questions. They do not relate to how far patients have had to travel.
Many of my students resisted the notion that they needed such numbers in order to act ethically. They clung to the idea that the ethical choice was to treat those patients who had managed to get to the hospital as effectively as possible. They would not take on board the fact that for the majority of patients in poor countries, to travel was not an option. It was difficult to convince these students that, as the people responsible for healthcare services, they would do more good if they focused on offering the basics, such as iron tablets for pregnant women and vaccines for children, to as many people as possible.
To me, the discussion of how to reach the poorest and most excluded was the core issue in my teaching. It went hand in hand with explaining how significant the differences in health service resources could be between different countries, even though all of them might have been categorized under the one label of “underdeveloped.” My explanations drew some strange responses, when students taking the course became aware of how much their target countries had developed over the last few decades. It could even make them disappointed and irritated. One day after lunch, when I returned to my office in the Uppsala Institute for International Child Health, a young woman was waiting for me.
“I wanted to speak to you one-on-one,” she said.
The preparatory course, scheduled to run for ten weeks, had only just started but I already recognized her as a very active participant. Her breathing sounded strained as she settled on the visitor’s chair next to my desk. Without saying a word, she put a letter in front of me with a hand that trembled a little. I noted the ornate letterhead with its elegant type. The sender was an official in Thailand’s Ministry of Health. The long message was written in English.
“This is a rejection of my application for a work permit to be employed as a nurse in Thailand. Can you believe it! They are telling me I can’t go there to work in the Baptist-run hospital in northern Thailand. I have been planning it for ages and already signed a contract with the Baptist Mission.”
The words poured from her. There was no mistaking how angry and desperate she felt. I was genuinely surprised. Via the Baptist Mission, Sida (the Swedish International Development Cooperation Agency) had funded her pay as a health service volunteer so her services would cost Thailand nothing.
“Exactly! I mean, why refuse?” she said. I did not understand the rationale either. I offered to phone the secretary of the mission, who I knew was very experienced. But, the angry nurse in my office told me, there was no need.
“I have already spoken with him. He explained that it’s Thai government policy to encourage hospitals funded by foreign states to employ only Thai nurses. He says there are actually unemployed local Thai nurses, though I find that hard to believe.”
I promised her I would look into the matter. She left my office, dejected.
The explanation in the letter from Thailand turned out to be perfectly true. Even back in 1972, Agneta and I had been impressed by the university hospital in Bangkok and, since then, Thailand had gone through a period of rapid social and economic development. In fifteen years the average per capita income had doubled and life expectancy had increased by ten years. It was reasonable that the country would prefer its own nurses to be employed in their home country. For one thing, they of course spoke Thai fluently.
The angry nurse who had been refused a work permit for Thailand was only the first of many students who alerted me to the fact that the world needed different kinds of skills, and so if my course was to continue it would have to start recruiting different kinds of students. That change had already happened by the time I left the Uppsala Institute for International Child Health in 1996, after thirteen years, to take up a post at the Karolinska Institute in Stockholm. By then, the students in my course were mostly qualified doctors and nurses who had short-term contracts to work for Médecins Sans Frontières at emergency clinics in disaster zones. Many so-called “underdeveloped countries” had followed the same route as Thailand and even countries that were still very poor, like Tanzania and Mozambique, had as many local doctors and nurses as they could afford to employ. Indeed, Africa had already begun to “export” healthcare staff to Western Europe and the Middle East. The old kind of Western doctor who had worked in African missions for ten or twenty years was no longer needed and no longer existed, and similarly there was no longer any need for Western doctors and nurses serving for a few years in aid organizations.
I had been very engaged in teaching throughout these years but I did not hesitate when offered a chance to return to research work—by a man from the Cuban embassy who turned up in my office one day in 1993.
He brought me a bottle of rum, arguably not the most appropriate gift to bring an expert in public health, and had an urgent reason for calling: an epidemic had started spreading in Cuba over the last few months. Characteristically, Castro’s regime had advised the media to keep quiet. The first sign of illness was a loss of sensation in the toes and then in both legs. The weakness could become so pronounced that the patient could barely walk. Sometimes, the sensory loss also included their fingers. As the condition progressed, the patient’s sight deteriorated, with large blind spots in their field of vision and changes in color perception. The underlying nerve damage was clearly very serious; worse still, the number of cases was truly alarming, at more than forty thousand.
“We have decided to ask foreign scientists to study this condition and we would love you to look into it,” the embassy official said.
I was certainly curious: scientifically speaking, the symptomatology was really exciting. But how should I design the research investigation?
It did not take me long to realize that the embassy official wasn’t here to inquire about my interest; he was a messenger from someone who had already decided that he wanted my help. I was known for having investigated poisoning caused by cassava—roots that were also eaten in Cuba.
“Can you come next week?” the embassy official asked me.
“What are you suggesting? Why didn’t you come to see me earlier and give me more warning?” I asked.
My daughter’s end-of-school exams were scheduled for the following week. In Sweden, this event, with all the surrounding ceremony, is a key rite of passage. I asked him if I could stay until after the ceremony, and then leave immediately afterward. He agreed.
“Good. But the research will cost a lot. Do you have the money to fund it?”
“Regrettably, we don’t,” he said. “Because of the crisis.”
At the time, Cuba was in the grip of a financial crisis that they had named el período especial, “the special period.” The Soviet Union, Cuba’s major trading partner, had initially saved the island economy, but the Soviet Union itself was going through its own political convulsions and collapse. Now, most everyday goods in Cuba, including food, were rationed, bus services were canceled, and electricity came on for a couple of hours in the evening but only in alternating districts. This was how the regime was trying to solve its problems, which, according to their frequently reiterated argument, were caused by el bloqueo—the blockade by the USA. In Cuba, they also spoke, but only in whispers, of el bloqueo interno—the internal blockade. For instance, you could not buy bananas in the streets of Havana because the farmers who grew them had to sell their produce to the state-owned company. This was due not to US sanctions but to the rigidity of state planning.
I applied to Sida for travel funds and was offered a grant within forty-eight hours. The team at Sida were not fans of the Cuban government, but the Cuban population was obviously suffering.
Preparations were made swiftly. Before long I was on a flight to Havana with Per Lundquist, a chemist from Linköping University. Once we arrived, we were in Cuban hands. “We’ll meet you at the airport,” they had told us. As soon as we descended the steps from the plane we were led away and driven to a VIP lounge where we were welcomed by a large reception committee. Two obviously important figures singled themselves out from the crowd: a man with crisply pressed trousers and polished shoes, and a woman wearing very red lipstick. The man introduced himself as the deputy minister of health and the woman as director of the Finlay Research Institute. Its name commemorated the Cuban epidemiologist Carlos Finlay, who had discovered that yellow fever is spread by mosquitoes.
I was discreetly informed that the woman, known as Conchita, was also a member of the politburo. It was clear that this was a very big thing: a member of the highest echelons of the Cuban Communist Party had come to meet me.
The following day we were collected from the hotel and driven to the Finlay Institute. The Cuban medical scientists who had been working on the epidemic—epidemiologists, clinicians, and laboratory scientists—were waiting to meet us. The atmosphere was tense with expectation. I felt like water in the desert, so eager were the Cubans to talk to foreign colleagues. Their presentations about the epidemic, who had been afflicted and where, were first class. Most of the cases had been found in Pinar del Río, a tobacco-growing province. We all lunched together and then returned to the laboratories, but we had hardly started working before the main door suddenly opened and several men came in. They moved about without making a sound because they all wore gym shoes. Each carried a handgun in his holster. They positioned themselves in the corners of the lab.
Then the boss entered. Fidel Castro.
I caught sight of his profile and just had time to think, “That’s Fidel Castro.” I had seen him on TV before and heard excerpts of his shouty speeches. The man now in front of me reminded me of the generously bearded Beppe Wolgers, the Swedish actor and poet. Castro gave himself time to greet the people in the room and ask after everyone’s families. When he caught sight of me, he broke into a slow jog and advanced toward me with open arms: “El sueco!” he exclaimed—the Swede!
I introduced my Swedish colleague but Castro was obviously more interested in me.
“What were you discussing when I came in?” he asked.
I told him about the course I was teaching and Castro asked questions about Mozambique and its socialist president.
“So, you worked in Mozambique when Samora Machel was president, and as a young man you joined the Social Democrats?”
At first, I couldn’t think where he was going with this. Then I realized that he had memorized my CV and was checking it.
“May I say something?” I decided to ask.
“Yes,” he replied, sounding a little curious.
“Mr. President, I would like to thank you personally, on behalf of all public health researchers. You have stated publicly that you have stopped smoking, even though you have long been identified with a fondness for large cigars. Indeed, you are in charge of a tobacco-producing country. It was a very significant statement.”
He laughed. The others in the room laughed with him, in a manner that is characteristic of people who work under a dictator. It is artificial laughter but not false; well-meaning but going on for a little too long. The dictators appreciate it for what it is: a show of respect.
Once Castro had left the room, our discussions resumed. The Cubans were intensely serious about their task and were happy to have us, but they must have wondered exactly why we were there—the epidemic was actually on the wane. However, they still did not know what had caused it. The intention behind our invitation was probably two-fold. In the first place, it was important to establish that the epidemic was not infectious. Second our presence showed the Cuban people that the country was open to international science.
The following day we were shown around hospitals in the capital and introduced to patients. In the ophthalmology department, I was impressed by the advanced treatments available for patients with sight problems. Consultants and groups of doctors specialized in discrete conditions such as cataract surgery, glaucoma, diabetic retinopathy, and so on. My Cuban colleagues responded to my curiosity and relished my clear admiration.
That evening a meeting had been arranged for us with members of the politburo and the Academy of Sciences. We met in one of the academy’s meeting rooms in its official home, a three-story concrete block. I had been asked to tell them about my impressions of the Finlay Institute and the hospitals we had been taken to see.
The conversation began smoothly but then I moved on to question their methods. Finding out what individuals have been eating is one of the most difficult things to investigate, even when the subject does their best to describe everything in detail. The inquiry must establish not only what the subject has eaten but also how much of each item, how it was cooked, and where it came from.
“I think you have been using the wrong methodology to find out about people’s food intake,” I said. “You have simply handed them a questionnaire. How can you be sure that what is written down is a correct account? For one thing, what about any informal trade in food stuffs? Is it possible that some toxic component might have been smuggled into Cuba?”
“The island is shut off so that’s impossible!” someone exclaimed.
They laughed but were clearly feeling defensive—not because they were loyal Cubans but because they were very skilled quantitative epidemiologists. They had mastered and refined numerical methods for calculating and comparing exposure to risk factors between groups of ill and well people. It was a bit much to ask them to tolerate an anthropological approach that called for varying questions asked in an open interview format, and which even assessed facial expressions and body language. To them this was fluffy methodology. At the time, in the 1990s, there was strong opposition between these two different ways of working.
Suddenly, the door opened and the silent men in gym shoes entered and distributed themselves into the corners of the room once again.
Castro followed. As before, I had had no pre-warning. Later, I realized that the entire meeting in the Academy of Sciences had actually been engineered to create a meeting between me and Fidel Castro.
He sat down in the armchair next to me. I praised the presentations we had seen.
“What do we do now?” he asked.
“My job is to find out whether something people have eaten might have caused the epidemic.”
“But the team have already investigated everything.”
“No, they have not investigated everything, because they relied on questionnaires. The list of questions focused only on the topics the investigators had already considered. No one has investigated what hasn’t yet been considered.”
The methodology discussion started all over again.
“Are people really telling the truth about what they have eaten? After all, the epidemic occurred during a período especial,” I said.
He interrupted me and his tone was now harsher.
“I assure you, the Cuban people have the greatest confidence in our health service.”
We were at a conversational dead end and no longer understood each other. Castro was visibly irritated and the Cuban scientists and officials shifted about restlessly in the large room, looking as expressionless as fish, while some exchanged pained glances, then stared down at the table top. They seemed eager to leave the room.
“May I tell you a story?” I asked.
I heard the words coming from my mouth. Castro seemed a little uneasy.
“A story? Of course, go ahead.” Our eyes met.
“When I was a young student, I watched footage of you and Che Guevara arriving here in Havana. You had come from Mexico in the ship Granma to start the Cuban revolution.”
“You have seen it?”
“Yes. It was filmed in black-and-white.”
“Do you remember the moment we stepped on land?”
“No, I don’t. I remember seeing you on board the ship. And then you were on land.”
“True. We never filmed the landing.”
A typical dictator’s device, testing me.
“But I saw the footage of the time when you lived among the people in the Sierra Maestra. You learned about their living conditions. You had been a privileged student beforehand and had never lived among people in remote regions. At first, you did not understand them.”
“That’s true,” he said.
“I remember seeing you sleeping in a small wooden shack and working with the Sierra people in the fields. You helped the children with their homework and the women with the cooking. You must have come to understand them well?”
“Yes. I understood them,” he said.
“Still there was one thing that surprised me. Something I did not see in the film. It was completely absent.”
“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 little 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 measures 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.
I told them that, globally, healthcare was improving steadily but they would argue back. My data must be wrong, they said, since they knew for a fact that environmental decay was causing more and more damage to public health. I also told them that the rate of population growth had been decreasing for the last twenty-five years and they countered by saying that no, the world’s population was growing faster than ever. Furthermore, they had learned that population growth was the major cause of environmental destruction. Some of them cared more for dead animals than the millions of dead children in poor countries. I tried to explain that the gorillas would have no future unless there were dramatic improvements in the living conditions of the people with whom they shared their habitat.
Time and time again, year after year, the same things were said in the same tone of voice. There were usually small groups of fanatical, emotional individuals and others who seemed calmer and more matter-of-fact. Each year, the majority of students tended to side with the activists.
This was during the 1990s, when a lot of public interest was focused on animal conservation rather than climate change. The extinction “red lists” were public and it was clear that many animals were at risk. Yet even organizations like the World Wide Fund for Nature grasped that saving the chimpanzees was impossible unless the people in the region had a decent standard of living. The activists, though, were not prepared to follow that line of thought.
For a few years, I would go home thinking about the students’ ideology and condemning it. Their most deeply rooted notion was that there were two different types of people, who lived in two different types of countries. When I sat in the cafes and listened to their conversations, I heard the world discussed in terms of “us” and “them”. The most common statements were endlessly repeated: “They simply can’t expect to live the way we do now, it wouldn’t work. Imagine if all Chinese people owned a car!”
In my view the students were right to say that it was going to be impossible for everyone to end up consuming resources at the current rate of the world’s wealthiest nations. But it was the wealthy nations who were going to have to reduce their consumption. The poorest should consume more while the large middle group should follow the wealthiest toward sustainable levels of consumption. Few students agreed with me, because the majority seemed convinced that the poor led contented lives in rain forests and small rural villages. Their insistence shocked me deeply. I remembered only too well how much people in poor parts of the world desired electricity, running water, roads, and access to education and healthcare.
Every academic year we created new courses and I took on the challenge of teaching a new batch of students about life at different levels of economic development. Above all, I tried to explain that there is no valid distinction between “us” and “them”. People are much the same all over the world, with standards of living that can be mapped on a continuous scale.
I would start my course by handing out oversize sheets of paper showing tables 1 to 5 from UNICEF’s annual report on children worldwide. The data sets for each country covered population size, economic development and health status, and included current data as well as the figures for the past year and twenty years ago. I asked the students to examine the tables and pick out the most successful countries. Clearly, if you looked at birth rates and child survival rates, the world could no longer be divided into two groups.
Most of the students proved resistant to facts. They claimed that the data from developing countries must be wrong. During the breaks and the Q&A sessions they explained to me that the population explosion was due to an increased birth rate among Africans, Muslims, and poor people—and that the rate at which these children died was the one thing that kept populations under control. I referred them to the data in front of them, which had come from the most reliable source within the United Nations, and said:
“Many decades have passed since child mortality acted as a check on population growth. The fastest population growth is now found in the poorest countries with the highest child mortality: people living in extreme poverty have more children because they need child labor and because they know some of their children might die. The only way forward is to carry on working to reduce both poverty and child deaths. Once parents see that children survive, they will want fewer, better-educated children. That is when you need to prioritize access to contraception.”
I was then, and still am, baffled at how hard this is to explain.
Several students would always reply that if these children lived, animals would die. I would go over it again: if more children lived, mothers would choose to have fewer children and the population size would stabilize, which would be in the interest of the animals as well. The main global health priority had to be to reduce child mortality in the poorest countries. One afternoon, a student stood up at the back of the theater and shouted at the top of his voice: “You’re like Hitler toward the animals!”
When I returned home at ten o’clock that evening, I realized it was time to accept that the way I was presenting the facts was not working. How could I demonstrate that their binary system did not exist? How could I show them that the world corresponded neither to the colonial concept of East and West, nor to the newer subdivision of North and South?
Then an idea came to me: I would represent each country as a bubble and its size would be proportional to the population size. If I drew a graph on which the horizontal axis showed income per head and the vertical axis provided an indicator of national health, like life expectancy or the number of surviving children per family, I could place the population bubbles onto it. That evening, I spent several hours on the first prototype. I used datasets from UNICEF’s yearbook and entered them into the statistics program StatView. By bedtime, I had printed out my prototype and put a copy in my rucksack. I wanted to test it out on my students as soon as possible.
The results were promising. The students seemed to like the idea of this new kind of world map. At that point, I could not foresee how significantly these bubbles would change my life.
The crucial step was taken one winter day in Stockholm in 1996. I hurried through the slushy snow, clutching a bundle of documents, on my way to the Karolinska Institute, where I was to be interviewed for the position of Chair in International Health. Being short-listed was more than I had expected, because several of the other applicants were much better qualified than me. So I had a plan for how to make a good impression.
When I arrived, the chairman of the committee, Professor Erling Norrby, asked me to step inside and sit at one end of an oval table. Eight professors, all older than me, were seated around the table. The sharp light of the winter day flooded in through a large widow and made their faces indistinct. Professor Norrby addressed me:
“Hans Rosling, you are our last candidate. We would like you to explain to us what you consider to be the core issues in the field of international health. And then please tell us why you are the right person to be appointed.”
I replied that the key fields of study were global variations in health and healthcare provision, and how best to promote and restore health among the poorest people. Then I continued:
“However, I don’t plan to convince you why I should be appointed. I’m aware that several of the other applicants are much better qualified than me. Instead, I am going to put you in the best possible position to choose the right person for the post by using my twenty minutes to teach you some fundamental things about global variations in health. I have studied the lists of your publications and know that none of you is an expert in this area. So, I have prepared copies of a colored bubble graph for you. Every bubble is a country and the color denotes its continent. The vertical axis shows life expectancy and the horizontal shows per capita income.”
I pointed to some examples: “Look, the range of countries runs from the Congo in the bottom left, where lives are short and the population is very poor, up to Japan in the top right, where lives are long and average income is high.”
I went on to explain the irrelevance of a binary division of the world into developed and underdeveloped countries, pointing out that most countries were clustered in the middle of the chart. I also argued that the disease burden gradually changed as economic development progressed, shifting from infections with or without malnutrition to non-infectious diseases, or predominantly late-onset, chronic conditions.
I kept the tempo up so that none of my interviewers would have time to be annoyed at the implication that they were incompetent. I actually found it good fun. My talk held their attention and even got a few positive comments. At the end, they asked me a few more questions and thanked me for my contribution. That same evening I learned that my friend Staffan Bergström had been appointed to the chair, as expected.
The true surprise, though, came the following morning when the telephone rang.
“Good morning, Hans. This is Erling, chairman of the international health appointment committee. You did not get the post, but we were so impressed by your presentation that we would like to offer you a six-year contract as Senior Lecturer.”
I took the post. A few years later, I was appointed to a professorship at the Karolinska Institute. My research had taken me as far as the interview short list but my teaching idea, with its use of colorful bubbles, had made me a professor.