Fear of ebola hit me hard one day in September 2014. That afternoon, I had spotted on Twitter an article about ebola, published in the New England Journal of Medicine, the USA’s most prestigious medical-research journal. The authors of the article were Chris Dye, Director of Strategy at the WHO, and his team.
Their research included a graph that made me freeze with dread: it showed a steep increase, week by week, in the number of new cases of ebola during the past month. The expected number of new cases for the weeks to come was also plotted on the graph. The spread of the epidemic would accelerate unless something drastic was done to stop the outbreak. I remember even reading some of the article out loud to myself.
The previous evening I had come home from making a presentation in Portugal and the following morning I was due to leave for Switzerland to make another. Despite this, I stayed up for a long time, absorbed by this crucial study. I had been aware of the ebola outbreak since February, when it was first mentioned in the news, and since August I had started to be seriously worried about the epidemic in western Africa. Yet during these past months, what I had felt was more a professional concern.
Chris Dye’s research team had used ebola data from the start of the epidemic up to September 14 to calculate an estimate of the expected number of cases per day as far ahead as early November. It was the way the line representing their predictions curved ever more steeply upward that was so frightening: the number of new cases per day had doubled every third week until mid-September, and their analysis indicated that this would continue if the response to the epidemic was not fast and effective enough.
Already by the beginning of September, people were dying in the streets of Monrovia, Liberia’s capital city, something that had not happened in modern times except during wartime or because of a natural disaster. So many people had fallen ill so quickly. The field medical facilities had soon run out of beds, and many patients never got treatment.
That graph predicted what would happen if the number of new cases continued to double every third week. Nine weeks later, at the start of November, the number of new patients per day would be not twice as many, not four times as many, but eight times as many as now.
If the cases increased at this rate, Monrovia, the place likely to be the most severely affected, would soon be paralyzed. The progression is called exponential growth or, if you prefer, explosive growth. The numbers suggested that, on average, each patient would infect two healthy individuals and each of them would become ill enough within a few weeks to infect two more, and so on. But it was not the figures in themselves that triggered my sense of fear, but imagining the situation in Monrovia in November, if this exponential growth of the disease continued unchecked. Liberia would sink into even greater chaos than during the recently ended civil war. Many would rush to leave the country. That would be catastrophic, because then the spread of the disease would become international and utterly unpredictable.
These fears changed our priorities at Gapminder that year. What could we do to help? We produced informative videos explaining the threat. Our focus was on attempting to explain what would happen if the number of new cases doubled every third week. Our short films were viewed by millions in just a few days.
The ebola outbreak had so far been almost totally confined to three small countries in West Africa: Guinea, Sierra Leone, and Liberia. Why then had fear of ebola grown so fast in Europe and North America during 2014? Because the deadly virus can be transported across borders and oceans inside a human body. Any infected individual who traveled elsewhere was liable to infect others wherever they ended up. The dread of the disease was, of course, heightened by the fact that there was still no effective treatment.
Six months earlier, at the end of March 2014, I had taken note in passing that the WHO had announced the spread of ebola from Guinea to Liberia. Little did I know that six months later I would have a desk of my own in Liberia’s Ministry of Health in Monrovia and that I would be working as the “Deputy Director of ebola Surveillance.” If, in addition, someone had told me that, because of ebola, this would be the first year that I would not celebrate Christmas and New Year with my wife and my family, it would have sounded like a bad joke. As it happened I ended up celebrating an unforgettable Christmas that year in the company of Luke Bawo, my roommate and boss in Liberia. Just before I left Liberia, I was honored by being accorded traditional chieftain status and given the title “Chief Tanue.”
It was only later in the autumn of 2014 that the reality dawned on me: I had to cancel or postpone all engagements and offer my services to the battle against ebola. Experts like me should have understood the extent of the danger earlier. Most of us took our time to grasp the urgency of the epidemic and so, too, did the rest of the world. The handful of expert epidemiologists and tropical-disease specialists who did see what was coming worked for the WHO and did not have the necessary kind of budget to take action.
Why did we fail in this way? We had for some time been observing several outbreaks of ebola, all in faraway African countries. During the second half of 2013 and the spring of 2014, the virus had been on the move from the remote highlands of rural Guinea to equally isolated regions of Liberia and Sierra Leone, but the world did not care. None of the outbreaks had spread to capital cities—that is, the infection had never come close to sites of government or to international airports.
Before long, though, there were cases in Conakry and Monrovia, the capitals of Guinea and Liberia respectively.
Public health professionals, and that includes me, should have reacted more quickly when cases of ebola started to spread to large cities with extensive slums. I blame myself, particularly, because I am not just any professor in global health: for decades, my research focused on epidemics in remote parts of rural Africa. The insight that ebola had the potential to become a major global threat if the infection spread to a capital city with a large slum population and an international airport was one I had already shared with most scientists working in this field. And now it had actually happened.
On August 8, 2014, the WHO declared that the ebola epidemic had become an acute danger to health on an international scale. Now, finally, everyone sat up and took notice. The alarm spread. Foreign investment stopped, at first leading to counterproductive measures such as flight cancelations and attempts to isolate the afflicted countries. Eventually, resources were diverted to control the disease in western Africa.
The worldwide fear felt at the time was completely justified but it surfaced too late. By then, all we could do was make up for lost time.
It was October 10. We were in the government building in Stockholm. Eugene Bushayija looked straight at me. He was clearly very worried; “No one understands what should be done about the ebola outbreak in Monrovia,” he said.
Eugene worked for Médecins Sans Frontières. We had just come to the end of a meeting with Swedish government officials and academics about what Sweden could contribute to stop the epidemic. Now, only the two of us were left in the meeting room and we found ourselves agreeing that nobody seemed to know exactly what was going on in western Africa.
Eugene went on: “MSF treatment centers are admitting as many ill patients as they have the capacity to treat. The majority test positive for ebola. But we’re not running the only facilities and because MSF is independent of the government, we can no longer be sure of the overall picture. Still, our center in Monrovia alone registered more confirmed cases than are shown in this week’s WHO report.”
I was very well aware that hard clinical work in field hospitals was unsuitable for someone of my age, but I felt there must be something I could do.
Ten days after the meeting in Stockholm, in late October 2014, I was at my new desk in Monrovia. I had brought a couple of suitcases full of everything I thought I might need: a laptop, a printer, a projector, spare memory sticks, and—not least—appropriate clothing. At first, Agneta had reservations. Did I really have to go? Was I desperate to prove to myself and others how brave I still was? We talked about my plan, and Agneta came to the conclusion that I probably could make a difference. I had her full support.
I spent the time on the plane reading up on ebola. Before landing, I prepared to protect myself against exposure to infection. What would the airport be like? I ought to have brought disinfectant wipes to clean my suitcase, I thought, as my head filled with all the likely and unlikely routes of infection. A friendly woman from the Swedish embassy picked me up at the airport and drove me to the Grand Hotel, where the embassy had booked a room for me. Before entering the hotel, I was shown a disinfectant routine: I had to wash my hands in a bucket of chlorinated water. The bucket was on a stool and on the floor next to it was a plastic basin also with chlorinated water for me to step into with my shoes on.
The hotel seemed to have been recently built. The lobby was an elegant space, with tall, freshly painted pale-yellow walls and pillars of dark-red stone supporting the high ceiling. To the right, I spotted an ATM and two small shops. The smiling receptionist handed me the key to a third-floor room.
I have never been so appreciative of a high-class, spotlessly clean hotel room as I was then. Yet the risks were still too great. I washed and cleaned myself as carefully as I have ever done, then I wiped all the wardrobe shelving with chlorhexidine-soaked wipes and obsessively placed my clothing in piles that did not touch the walls. Then I cleaned the desk and the outside of my suitcases with more disinfectant wipes. Finally, I went to bed, slept restlessly and dreamed I was running a fever. Fear of infection stayed with me throughout my time in Monrovia, but after a week or two these preparations had turned into a daily routine that I hardly noticed.
During my first day in Monrovia, I was given an overview of the local response to the epidemic. Everywhere was full of frantic activity. Experts were crowded into small rooms with maps of Liberia on the walls. I was ushered in and out of tall office buildings, always stopping at the entrance for the compulsory washing of hands and shoes in chlorinated water. Introductions went easily at the American office run by the federal Centers for Disease Control and Prevention (CDC) because the staff recognized me from my TED talks. They were extremely keen to find out what I was doing in Liberia and surprised to learn that I had come to work for several months as an independent expert.
Liberia’s Deputy Chief Medical Officer Tolbert Nyenswah also recognized me when we came across each other in one of the many corridors I wandered along that day. I gave him my Karolinska Institute card and explained that I had been investigating epidemics in poor African countries for almost twenty years, after first working as a district doctor in the public health service in Mozambique.
“In other words, I do understand what shortage of resources can mean,” I added.
He nodded, his expression a mixture of surprise and approval. There was no reason he should have known of my background before I went on the lecture circuit. I bent down to get a letter from my bag.
“I have brought with me a letter to your president, Ellen Johnson Sirleaf. It is from the Royal Academy of Sciences in Stockholm. May I deliver it through you?”
It had been beautifully handwritten on the academy’s thick correspondence paper. The permanent secretary, Staffan Normark, as a representative not only of the academy but also the entire international scientific establishment, was apologizing that research into ebola had not advanced further than it had at present.
This had troubled me, too. We, a group of experts on international public health, had earlier compiled a list of seventeen diseases needing further research into treatment, and presented it to the pharmaceutical companies. Ebola was included in the list. Because the research has not been carried out, simple test methods, vaccines, and disease-specific medication were not available.
Tolbert’s face was serious as he read the brief letter. Then he sighed a little, looked up at me with screwed-up eyes and, after a moment’s silence, said to me: “Thank you. We have never been addressed in these terms before. The president will appreciate this apology.”
In another corridor I was introduced to Liberia’s ultra-efficient deputy minister of health. He told me: “Please join us tomorrow at the coordination meeting. It’s on the ground floor and starts at nine. I will introduce you to our own leaders of the disease response and also the experts from abroad. You are very welcome here.”
My admiration and respect for Tolbert Nyenswah’s outstanding leadership ability, and the calm, thoughtful way in which he managed the entire response to the ebola outbreak, would continue to grow during the months I had the privilege of working under him.
Back in my cool, air-conditioned hotel room after my first day, I felt anxious about infection in my sweaty clothes. I wiped my bag down with paper napkins soaked in hand-cleaning alcohol. I stripped, wiped my belt with more napkins, and put all my clothes in the laundry basket. I showered. The whole cleansing process, which included paying extra careful attention to my nails, took more than half an hour. Wearing only a clean pair of underpants, I folded back the bedspread, blanket, and top sheet and lay down on the bed.
Lying there, I reflected on my first day. It had worked out unexpectedly well but I felt doubtful nonetheless. Would I achieve what I had set out to do? I also felt a little ashamed about my ultra-intensive cleaning routine, but it had calmed me, too, and would become a soothing ritual that I carried out each day.
I rested for a little longer and then took the elevator to the top-floor restaurant, had an excellent buffet dinner and rounded it off by sipping a Coca-Cola beneath the black, star-studded sky. The tropical night was warm up there on the roof terrace. A grant from the Wallenberg Foundations, which fund research deemed beneficial to Sweden, had made it possible for me to stay in the best hotel in Monrovia. I resolutely silenced my critical conscience but told myself sternly: “You shall have to make up for all this by working hard.” Back in my room, I fell asleep quickly, but was woken by a nightmare where I fell ill with fever and diarrhea.
“Why does the WHO report say that the current number of confirmed ebola cases in Monrovia is close to zero? It’s obviously not true!” I spoke frankly at the following morning’s meeting with the staff at the American CDC office.
This had also not escaped Frank Mahoney, one of the world’s best, most experienced infection epidemiologists. It had infuriated him and he launched into a systematic account of what he thought were the reasons. Frank was short and a bit overweight, with a crew cut and unshaven chin. He wore an ill-fitting dark jacket with a limp tie. His colleague Joel Montgomery, also a very skilled infection epidemiologist, just as his shirt was a little whiter and his hair a fraction longer than Frank’s, spoke more calmly.
Both men thought the problem stemmed somehow from the epidemic surveillance office at the Ministry of Health. Its head was a Liberian called Luke Bawo. Terry Lo, another American epidemiologist, cut into my questions and speculations: “I think you should go to the ministry and chat to him. He’s very easy to talk to. I’m working with his group there. Why don’t you come along with me after this meeting?”
It was late morning when we set out, and the sun was flooding Monrovia with light. A quarter of an hour later, the car pulled up in front of the health ministry’s three-story building of yellowing concrete. Around the car park, filled mostly with white jeeps bearing the ministry’s logo, was a high wall of the same discolored concrete.
Before we were allowed into its long corridors, guards at the entrance to the ministry kept watchful eyes on us to check that we followed the chlorinated-water sanitation regime. Terry Lo took me to his office, where people were hard at work at the four desks they had managed to squeeze into the room.
“I’m managing the HISP database,” a middle-aged Irishman and WHO staffer said.
“HISP? What is that?” I asked.
They all stared at me, obviously baffled at my failure to recognize the acronym.
“The Health Information System Data.”
Just as I was about to start asking questions about the data-entry system, the door was pushed open. The newcomer stepped quickly inside. The swiftness of his movements was amazing because he had a gammy leg that he had to push forward with his hand. No one seemed to notice, though, and he was very much in control of his movements, suggesting that he had coped with his handicap for a long time.
Terry gestured to catch his attention: “Professor Rosling, I’d like to introduce our boss, Luke Bawo.”
Luke spoke in a broad, Liberian-accented English, and I had to strain to follow what soon became a lively conversation. Keen to find out what I was doing there, he asked me some straightforward questions. I said that I wanted very much to contribute to the ministry’s efforts to control ebola and added that I was fully financed to work in an independent capacity.
“Trouble is, another desk will hardly fit in here,” I finally pointed out.
That was easily dealt with. Quickly, Luke ushered me into the room next door and made a welcoming gesture. It had an air-conditioning unit, a small fridge, and two green-painted metal desks with tops made of brown-speckled plastic. The larger of the two desks was stacked high with piles of paper, boxes and a printer. The smaller one was empty.
Luke pointed at it: “That is your desk.”
“Thank you,” I said, pleased and surprised. “And whose desk is that?” I asked, indicating the larger one.
“It’s mine. You will be based in my room, as the deputy head of ebola surveillance. We can easily share the work between us here. You can have a key of your own, I have a spare. There’s room for your bag as well,” he said and pointed to a space behind my desk.
He was not being bossy but spoke calmly and pleasantly as if all these things were perfectly natural. Then, his face and voice grew more serious.
“We really need you in Liberia. Will this be all right for you?” he asked, looking deep into my eyes. I liked his unaffected, direct manner but felt quite startled: less than twenty minutes after walking through the front door, I had been offered an official post in the ministry. My thoughts flashed back over how smoothly everything had run, from the immediate reply to my inquiry about a UN secondment to the completion of my preparations in Sweden. I had ended up in the best hotel in town and had gained the best possible impression of the Liberian in charge of the battle against ebola.
Since then, I have reflected on how quickly I made up my mind.
“Yes, it’s great. But is it really this simple? Ought we not write an agreement and sign it, both of us?” I asked.
“No need for that,” Luke said.
Luke would go on to meet all my expectations of a good boss. We became very close friends and since I couldn’t spend that Christmas with my own family, I spent it with his. Within a few days, I had my business cards bearing the ministry logo and a little later I received a gift of several stunning, colorful West African shirts.
“You must stop wearing your pale blue shirts,” Luke said. “These will make you look like one of us.”
He had a good reason for his gift. Most of the foreign staff employed in the battle against ebola were equipped with T-shirts, vests, and caps bearing the logos or initials of their organizations. My clothes had to show who I was: an official, employed by the Ministry of Health and the government of Liberia.
My role was to work with Luke’s staff to compile the figures and write the text of the daily, ten-page report, which Luke then checked and published.
The problem with the report soon became painfully obvious. The staff relied on a database provided by the CDC. The recording routines had functioned well enough during previous ebola outbreaks. In this outbreak, however, the daily number of confirmed cases was much larger than before.
On my first day, I discovered that not every one of the thirteen Liberian country districts provided daily reports. The reason was the irregularity of contact via email and telephone, and the outcome was that a classic error was introduced: the entry “zero” stood for “no new cases,” but where there was no report at all it was also entered as “zero.” My first intervention was to introduce a “black box” in the table when no report was available, instead of a zero.
Another problem was that getting in touch with the district officials reporting on ebola was done at the personal expense of ministry staff, who had to use their own phones and public phone cards to talk to colleagues in remote regions. The ministerial budget did not stretch to cover all these calls, and the international organizations, with their huge economic resources, had omitted to give telephone cards to key personnel, presumably to “prevent corruption.”
It did not take me long to set up a dedicated funding scheme by way of an agreement between Gapminder and the Liberian Ministry of Health. The aim was to provide free telephone cards for members of staff and there was only one restriction: the cards must be used both to contact colleagues, and to call friends and relations around the country every evening, to gather information and pick up on rumors of new cases. The only other, very strict rule was that anyone caught selling “air time” on the cards would be in deep trouble. The phone card fund was financed by minor donations from Swedish philanthropic sources who wanted to contribute to the fight against ebola, and administered by Gapminder. This highly cost-effective and quickly implemented measure was made possible thanks to my position at the ministry and support from The World We Want Foundation, the Jochnick Foundation, and the Anders Wall Foundation.
In August and September 2014, in the weeks running up to the publication of the academic article that finally prompted me to take action, the slums in Monrovia had suffered the world’s largest ever outbreak of ebola in a densely populated area. The CDC database had been built to accommodate separate inputs from three sources: first, an examination of the patient at home, second, an examination of the patient on admittance to a treatment facility, and third, the laboratory test results. By the second half of September, a few weeks before I arrived in Monrovia, this system had imploded.
Data collection became impossible because the three-step input requirement presupposed consistent identification of the patient at every stage, by an ID card or similar. One person had to take a note of the examination in the patient’s home; next the clinic staff had to report the admission; and, last but not least, when the patient’s blood sample had been analyzed in a laboratory, the result had to be added to that individual’s data set.
Because Liberians were identified only by name, address, age, and gender, and not by a unique identifying number, minor variations in the spelling of names or errors with house numbers could cause the entire thing to fall apart. It was perfectly possible for the same person to be counted three times. So, of course, no one trusted the figures. That also meant that the laboratories started entering the blood-sample data into their own Excel spreadsheets, which they did not share.
Everyone involved was more or less aware what was going on but no one in an advisory or executive position was prepared to accept the need for drastic change. A simplified reporting system had to be introduced to give the authorities a proper overview of the course of the epidemic. I drew up some new guidelines. As Luke looked through them he appeared worried: “What will the WHO say if we get rid of their format?”
“They will have to put up with it.”
As Luke continued to go through my suggestions, I stressed that we had to get the data in order fast, as we had a crisis on our hands. But what foreign agency could I possibly get to work on the huge backlog of lab data?
“I’m going to ask my boss in Stockholm. His name is Ola Rosling and he is actually my son. He is also a very fast Excel data compiler.”
The suggestion made Luke beam. Within a few hours, all the laboratory Excel files had been transferred to Ola. He got up early in the morning and began to compile all the test data from a total of 6,582 blood samples. First thing the following morning, I checked my email and found the completed and reliable graphic representation of the number of new cases of ebola. And happily, the graph indicated that the number of confirmed cases was already declining.
“I’ve figured out a good solution, I think,” Moses Massaquoi said one day at the beginning of December. Moses was a jovial man with an incisive mind. He carried the responsibility for all Liberia’s treatment facilities and was one of the country’s six leaders of the fight against ebola. What he had devised was a way to deal with an unexpected and rather irksome problem. That morning, a few Liberians and I had lingered after the end of the coordination meeting. I had just shown the latest graph, which showed that the number of new cases in Monrovia was continuing to fall and was now below ten per day.
Moses had also displayed a data set: the five functional treatment facilities in the capital were almost empty—there were six hundred unoccupied beds. The troubling fact was that several international organizations had been slow off the mark with the promised construction of the additional treatment units and now that they had finally been built, they were no longer needed.
“It wouldn’t have become a problem if these guys had simply accepted the facts and refrained from carrying out their plans,” Moses said and sighed deeply. He turned to Tolbert and explained that, regardless of what we had agreed with the heads of organizations at coordination meetings, foreign ambassadors took it upon themselves to see the president and insist on going ahead with the buildings. Apparently, it was hugely important to have reports of the opening ceremonies shown on television back home.
“It’s true, the president is under pressure. What’s this smart solution you’ve cooked up?” Tolbert asked.
“We arrange a solemn ceremony for them. Military choir and music, someone from the ministry on hand to thank the ambassador in front of the entrance. Staff lined up wearing full protective kit. Great TV, right? But we only let them hand over the units to us, not open them for admissions. Not until we’ve agreed on wider uses for patients with conditions other than ebola.”
Everyone grinned broadly at Moses’s brilliant idea.
“It could work. I’ll have a word with them,” Tolbert said, still laughing.
This exchange must not be misunderstood: the overwhelming majority of the international aid organizations made very valuable contributions. It was only when it came to reporting their work for outside audiences that most of them seemed ready to resort to gross manipulations. I assume the main reason was self-preservation, because they had to ensure financial support from their base, be it government grants or public donations. Or perhaps it could be about a particular charity boss securing their position. Whatever the reasons, from the Liberian perspective their behavior was not helpful.
During November, the number of new ebola cases in Liberia fell quickly. The outbreaks in the countryside were brought under control, one after the other. By the end of November, the graph suggested the epidemic could be over before Christmas.
In order to avoid the illusion that we might soon give the all-clear, I re-plotted the graph with the cases shown on a logarithmic scale on the y-axis. It showed that the outbreak would end as it began—following a slow course with fewer and fewer cases but with sudden flare-ups. The success in the fight against ebola had to a large extent been due to the Liberian public having grasped what was needed, like local shops setting up hand-washing areas, and parents keeping children out of school.
During December, work to control the epidemic was marked by the psychological effects of sheer tiredness on the part of the clinical staff. Patients admitted to the nearly empty units were well cared for but the follow-up and, notably, contact-tracing was far from ideal. Data analyses were incomplete as work became routine for most people. It was very important to reset thought patterns—to re-prioritize. The guiding concept should be a phase-change, as I called it, of our main task: with the “fireman phase” completed, the “detective phase” must begin. It meant, among other things, that we registered cases by name rather than by numbers. The tracing of patient contacts must be perfect if this epidemic was ever going to be stopped.
This was why I decided, in the middle of December, to shift half of my work schedule away from epidemiological surveillance at the ministry to a new base in the office of the capital’s contact-tracing group. I also organized a “war room,” which was used for meetings dealing with the reports that came in every morning to the coordinator of the contact unit. The room was also a workplace for the epidemiologists employed by the international organizations at work in different sectors of the country.
One central task was to mark all cases on a detailed map of the city. Another, equally important one was to indicate on the map where possible contacts lived, as reported by patients. It gave us a citywide overview of the spread of the disease.
As soon as we found out that someone had died from ebola, we would compile a list of all physical contacts that the dead person might have had. During the very first few days after becoming infected, an infected individual was not infectious to others. It was when their symptoms were just becoming noticeable that we needed to isolate them. This was the key to stopping the spread of the virus. We scrutinized the lists and made daily rounds of home visits to find people who might have been close to an ebola patient.
One day, a boy went missing from a family on our list. His mother claimed to have no idea where he was. Actually, she was reluctant to tell us. In cases like this, we turned to Mosoka Fallah, a Liberian with a doctorate in epidemiology, a generous heart, and a sharp brain.
Mosoka went to talk to the woman. She was a single mother because her husband had left her. The boy had been taken away by his dad, she admitted. It happened now and then, and she couldn’t stop it. It is typical of the lot of women in poor communities. For one thing, there is no official help—no emergency services to call.
Gently, Mosoka persuaded her to get the boy back. Because she couldn’t afford the fares for a journey across the city, Mosoka gave her money and she agreed to go the next day.
Then she looked at the notes in her hand: “I can’t use these, such new, crisp notes. It won’t help if I crunch them up—he will see they’re new all the same.”
In the slums, bank notes are worn and tattered because they do the rounds hundreds and hundreds of times. Her former husband would spot straightaway that some wealthy person had given her cash in hand. She was frightened that he would become angry and uncooperative if he thought she was sharing any kind of information about their lives with people he didn’t know. Nothing must give her away.
So Mosoka fixed her up with old notes and she brought the boy home the following day. Not only that: because she now trusted Mosoka, she became a contact-tracer for us. Mosoka Fallah had understood that in the fight against epidemics, your mind must encompass a love of humanity as well as spreadsheets.
In the ebola epidemic, it was even more important than usual to empathize with people’s needs as well as to think in numbers. Identifying exactly where the numbers of new cases were increasing or decreasing was one of our hardest tasks, and burials created special problems in this regard. We could not understand why, in these extreme conditions, it was still essential to transport a corpse to the home village to be buried.
I remember one such case very well. A grandmother had contracted ebola, quickly became very ill and died. Her family had promised to fulfill her wish to be buried next to her husband. They kept their promise: they washed her body, clothed it in a nice dress and loaded it into a run-down taxi. The cab driver was paid risk money for the trip to the grandmother’s home village and the family jumped in next to the body. Granny was buried and ebola was spread to another village. We tried to communicate the precautionary message but often in vain.
It was hard to grasp why it should be so. How could people be so thoughtless? But it was not a matter of being clever or stupid. In the example above, it was all about love for a mother or a grandmother, the heroic woman who had helped her family all her life, perhaps also during the civil war. Was the most important duty to her or to the authorities? For most people, such choices were hard.
We knew we should be offering grants toward burials, and managed to do this toward the end of the epidemic for some cases. People were allowed to decide where to bury their dead but were given a shroud by the Red Cross, a body wrap that left the face exposed. The actual ceremony was conducted with the help of “funeral assistants” in protective clothing, who placed the body in the grave. It worked well as long as the assistants were humane as well as technically well-informed.
“Can I come in?”
There was a gentle knock and a woman put her head round the office door. Her black hair had been plaited into two beautiful, long, thin plaits that framed her face and flowed over her shoulders. I recognized her: Miatta Gbanya, the head of finance in the Ministry of Health who had been appointed deputy leader of the countrywide response to ebola. I invited her in and said that she was always welcome.
“I actually need to have a word with Luke. Do you know where he is?”
I didn’t, but expected him back soon because we had the daily report to go through.
This was near the end of November. Because the number of new confirmed cases was definitely shrinking, our days had become less hectic.
“Have a seat, you surely need a few minutes’ rest,” I said and pulled out a chair for her.
We had discussed official issues on several occasions but it was a privilege to spend a few minutes with the busiest civil servant in charge of ebola control. I knew that Miatta Gbanya grew up during the civil war, trained in nursing, and had joined the work of humanitarian organizations in the Congo and South Sudan. She later went off to Bangladesh to study at its best university and acquired a master’s degree in public health.
I admired her a great deal and also had a question for her that I so far had not dared to ask. She seemed in a good mood, so this might be the right moment to satisfy my curiosity.
“I have gathered that the worst time was the month before I arrived at the end of October. What was it like for you then? What was the most difficult thing you had to deal with?”
She looked thoughtful. So many bad things had happened then.
“Perhaps the very worst moment was at the beginning of October. I was on the phone to the States. They had been persuaded to donate extra generously to ebola control measures, but I had to tell them that they were about to make their funding conditional on the wrong things. I had my work mobile in my left hand…” She clapped her hand to her left ear. “Then my private mobile rang. It was my cousin, who sounded upset, and I asked the US negotiator to hold for just half a minute to let me take this other call. Fine, he said, but keep it short, our decision has to be made within a few minutes.”
She raised her other hand to the right ear: “My cousin was in tears. Her mother had become ill with fever and diarrhea. My cousin had taken her to an ebola clinic but they couldn’t admit anyone, there was a queue already. ‘Please, can you help?’ So, there I was, with the responsibility for the nation on my left and for my dear aunt on my right,” Miatta said.
She fell silent. Her eyes were looking past me with her hands still covering her ears.
I whispered after a while: “What did you choose, your nation or your family?”
Now Miatta looked me in the eye.
“I chose the nation, just as all of us in leadership positions did that autumn. As we did here in the Ministry of Health every single day. During the day, we never stopped working. But at night we wept for the dead, for our friends and colleagues and relatives. Then, slowly, we got the support we needed and began to win against the virus.”
I asked the final, necessary question: “What happened to your aunt?”
“She died. It was ebola,” Miatta said, as if it had been inevitable.
We were silent for a long while and then I spoke again: “I have been extremely impressed by the work you are all doing. Before I came here, I had accepted what the European media was saying—that the situation was chaotic before international epidemiologists took control.”
“Sure. I realize that’s how we are portrayed. They are all so crazy about their own organizations. Some of them are great and bring lots of very fine people here to help us. But they want to be praised, the more the better.”
She was laughing rather cynically when Luke came in.
“What, are you laughing at me when my back is turned?” he said jokingly.
“No way, we’re laughing at the sharks who love being praised,” Miatta said happily.
I had already noted that when the leading Liberians felt irritated and exhausted, they used this term for international organizations: “the sharks.”
By the beginning of 2015, for the first time since June 2014, fewer than one hundred new confirmed cases were reported in one week for Liberia, Guinea, and Sierra Leone together.
By then, I had returned to the engagements I had put on hold while I went to work on ebola. In January 2015, Agneta and I traveled for a second time to the World Economic Forum in Davos. I was hauling an enormous black suitcase, which was difficult to fit into the luggage compartment on the train.
I was booked to speak in front of a thousand-strong audience in the plenary hall. The presentations from me and Bill and Melinda Gates were to be the first of the main session on Friday night. Our title was Sustainable Development and the schedule straightforward: Bill and Melinda Gates would be in conversation about “A Vision for the Future” with the CNN news presenter Fareed Zakaria for about thirty minutes. Before the start of their event, I would have fifteen minutes to speak about “Demystifying the Facts.”
Which is where the black suitcase came in.
It was full of audience-response devices, one for each member of the audience. Our plan was to find out what the assembled elite knew about the fundamental facts of today’s world. The congress organizers were thrilled. They helped put the devices on the guests’ chairs before the doors opened. We at Gapminder had used these devices before to investigate how much particular groups of people knew, and the results had been remarkably disappointing across many different sectors—bankers, politicians, the media and activists at international organizations. Across the board, my lecture audiences tended toward a world view that was thirty years out of date.
This time, though, I thought the results would surely be different. Everyone in that hall was a world leader in his or her field. When I walked out on the stage, I spotted Kofi Annan, the former secretary general of the UN, and his wife in the front row.
I felt quite nervous when I introduced myself.
“I’m going to start by asking you to answer three questions.”
The first question came up on the big screen behind me, and then the three multiple choice answers:
During the last twenty years, the proportion of people living in extreme poverty has … a) Almost doubled; b) Remained about the same; c) Almost halved.
I watched Kofi Annan as he quickly pressed an answer button. Time for the next question:
How many of the world’s one-year-olds are vaccinated against measles? a) Two out of every ten; b) Five out of ten; c) Eight out of ten.
I observed furrowed brows in the hall. My screen showed that the answers were coming in quickly. The technology was working.
I moved on to my last question, which was about the number of children in the world. To illustrate the number, I showed a line graph. In 1950, there had been fewer than 1 billion children and the number had increased steadily until the beginning of the twenty-first century.
What would happen next? The audience saw three options shown as dotted lines: the A line was going up to reach 4 billion children by the year 2100; the B line pointed less steeply upward to 3 billion children; the C line was static, i.e. the number of children would still be 2 billion by the end of the twenty-first century.
This question arguably concerned the world’s most fundamental demographic fact.
The audience looked uneasy. Kofi Annan leaned closer to his wife to confer with her. The answers came in more slowly than before but finally everybody had replied.
I showed them how they had done. The question about the proportion of people in extreme poverty had been answered correctly by 61 percent of the Davos delegates—it had been halved in twenty years. Davos delegates had done much better than the Swedish population. Only 23 percent of those polled in Sweden had got the answer right. In the USA, it had been 5 percent.
Then I looked at the question about measles. It was very much an issue of the moment. Many politicians, public-health experts and pharmaceutical-company bosses were in attendance. Besides, Bill and Melinda would soon be speaking on behalf of their foundation, which funded vaccinations for the world’s poorest children on a grand scale. I had every reason to assume that the majority of these powerful people would be aware of vaccination rates: more than 80 percent of all one-year-olds.
In fact, only a shockingly low 23 percent of the audience knew the right answer.
What about the demographic question? The right answer is that the number of children is no longer increasing and looks unlikely to change significantly for the rest of this century. The birth rate has stabilized to 130 million children annually because 80 percent of couples worldwide use contraception and the majority of women have access to abortions.
So, how many got this right? Only 26 percent, which is still a whole lot better than people in Sweden and the USA, who managed 11 percent and 8 percent respectively.
I couldn’t resist provoking my audience by mentioning the chimpanzees. If chimps in a zoo are offered a choice of bananas marked A, B, or C, they will, by picking randomly, pick each letter 33 percent of the time. Similarly, a group of people with no idea about the right answers could at least be expected to pick correctly one third of the time, just by guessing. This elite audience, after queuing to attend a seminar on socioeconomic and sustainable development, did worse than chimps would on two out of the three questions.
Gapminder’s clear, comprehensibly presented data sets have been an amazing success. We have improved the understanding of more than 6 million people every year through discussing our observations in ten TED talks, two BBC documentaries, and many open-access videos and visualization programs. But despite all our efforts to disseminate knowledge, we seemed at best to have had marginal effects on the worldviews of those who were actually meant to know most. This was serious. My questions at Davos were not trivia. They were about fundamental patterns of change in the world.
What is the most accurate way of describing the proportion of extremely poor people: sharply increasing, more or less unchanging or rapidly decreasing? These are radically different alternatives, comparable to basic road sense: is it right to drive when the light is green or yellow or red?
To ask what the proportion is of all one-year-olds who have been vaccinated against measles is the equivalent of asking what the proportion is of all children who have access to basic healthcare. Any answer other than 80 percent reveals that you are thirty years behind your time.
Anyone who does not know that most people have access to contraception and that the total number of children worldwide is no longer increasing has failed to grasp essential demographic facts.
When I returned to Stockholm, I told Ola and Anna that not even the Davos delegates knew the facts about the world, a world that classed them as very important people. We agreed it was time to change our approach. My conclusion was that we should try to produce better teaching material, but Ola and Anna disagreed. Anna stressed that what we had was already very good. Something else was needed. Perhaps the public and the experts in “the old West” were all psychologically blocked when it came to having a realistic understanding of “the other world.” Our new job had to be to grab people’s attention and make them understand what makes ignorance so persistent.
A little later, Ola and Anna formulated a concept: “Factfulness.”
We made it the title of our book and began at once to set out our thoughts.