Facts and Fiction on Global Health by Hans Rosling, Professor of International Health Karolinska Institutet, Stockholm Director of Gapminder Foundation web: www.gapminder.org

Global Pulse interviews Hans Rosling over tea in New Delhi.

RR: “How did you go from being a medical student to a health data guru?”

From Medical Student Backpacker to Disneyfying Information
HR: “As a young medical student from Sweden, I visited India with my wife. We were backpackers but everyone thought we were hippies….We were on the train 3rd class sleeper. “Are you hippies?” people asked. “No we’re medical students” we replied. “Oh, medical students, there are two tribes of you: hippies and medical students”. We traveled around Asia for 6 months on less than a dollar a day. It was an amazing unequal world at that time. The exchange rate was favorable for us. After medical school I joined the Anti-Apartheid Movement in Sweden that’s how I got involved with the newly independent states in Africa... that is how I got invited by the President of the Mozambique Liberation Front.

Understanding the world takes more than statistics, it takes more than formal knowledge, it takes that personal experience of being with and respecting colleagues in other countries. When you can merge those emotional personal experiences with broad formal academic knowledge … you can see magnitudes of difference and seas of change. What I’m doing now in life, is Disneyfying information about the world, I make Pocahontas stories. If you don’t make a narrative about changes in the world, if you don’t dissect what is going on, you can’t change people’s views of the world. Otherwise we fall back into the colonial view of the West and the rest of the world.

Medical Student Graduate Becomes Doctor for 60,000 in Mozambique
HR: After medical school in 1975, I went to Mozambique, which had an exodus of Portuguese and European doctors and I became a District Medical Officer in Northern Mozambique. For 5 million people there were less than 40 physicians.  I became the only physician for 60,000 people.  My experience working in a very privileged situation in Sweden, peaceful for hundreds of years with a good public health system, and then going to work amongst the most scarce resources was an enormous experience. To manage health services, there was quite good health policy in Mozambique, we were trying to do promotional health services. I developed a method for chloroquine resistant fevers. After doing a lumbar puncture, we’d put a piece of paper under the drops and if it wasn’t clear, we’d give ampicillin.

Life plans for you. Don’t try to plan too much and never finish things. If you finish things you’ll miss an opportunity that comes up.

Discovering a New Disease = PhD and Losing 2 Decades of Your life
HR: On August 21st, 1981 I got a message from an Italian nun in a remote health post about paralyzed children between 2 and 8 years with a spastic paralysis of both legs and sudden onset with no fever, sensory loss, or other symptoms. It turned out to be a new disease entity. I went through my textbook and found lathyrus sativa. We had an epidemic outbreak of Lathyrus without lathyrus sativa. When we looked at the data we knew we had an outbreak [but didn’t know how] at the same time we had a South African submarine nearby and we thought it could be biological warfare. When you have such an epidemic curve what is the main thing that occupies your mind? The main intellectual challenge? It’s that you get so scared to get infected yourself – it infects your intellectual thinking.  You think “I can’t infect my wife and children” so they were evacuated to the next town.   Then what do the people think if the doctor sends his family out? If I talk to the political leaders they will set up a road block which makes life worse for the poor people. We got help from the Ministry of Health.

We had to do an epidemiological survey of half a million people within weeks and there were almost no resources. The Minister of Health sent the last batch of nursing graduates to take over the health survey. . . and we confiscated motorbikes to collect data. When we looked at the geographic area, we noticed the outbreak was limited to an inland area close to the coast, which was entirely dependent on cassava and they hadn’t processed it well. They had lost all other crops, no leafy vegetables, no groundnuts, no beans or anything. The time period coincided with that diet. The ecological level we found was more powerful than the individual study. We gave the report to the Minister and went back to Sweden and then I had the responsibility of having found a new disease related to cyanide in cassava, eventually we named it Konzo.  In Sweden I met with cyanide scientists, went back and did a follow-up, and did my PhD thesis on this. To make a long story short, I spent the next 20 years on this disease. So be careful when you run into a new disease, it will cut out 2 decades of your life, until you have supervised 10 PhD students, written 100 papers, and a chapter in a textbook.

Convincing Fidel for Qualitative & other Research Collaborations
HR: Having the privilege and serendipity, I went to St. John’s in Bangalore India, Mozambique, and in the middle I was invited to Cuba. So I was the first foreigner who could do a field survey going house to house after the Revolution. I had very harsh nights quarrelling with Fidel Castro about the study design and I won. I convinced him that we had to use qualitative methods to understand the reality in Cuba. I became in charge of the research collaboration with Sweden and Iran and many other countries like Vietnam and Uganda.

Poverty, “Developing Countries,” and the Birth of a Graph
HR: My research in Africa interested me in studying severe poverty in remote parts of very poor countries. I learned to do classical geographical epidemiology.  Geographical, temporal, social distribution. We measured cyanide poisoning and time of disease in a case series study, which we published in the Lancet with only 3 patients. Then I began asking myself why are these rural communities collapsing? Why are economies collapsing? I understood how subsidized goods in the United States and Europe hit the poor parts of Africa. Before medicine I was very interested in social and economic development so I came back to that.

Then I began to teach Global Health. It was really because I was furious about this concept of “Developing Countries.” People put Argentina, Mozambique, and Thailand into the same box and labeled them “developing countries.” It doesn’t make sense to me. . . . The concept I saw of the world of “developing world” didn’t fit with my experience, it didn’t fit with the data, so that’s when I developed a little graph with GDP on the X axis and Child Survival on the Y axis and thought “it’s a continuous world.” Congo and Afghanistan on the bottom, India 1/3 up, Brazil 2/3 up.  It didn’t show “the west and the rest” it showed a continuum.

The Fruits of Child Labor & The Limits of Global Governance
HR: I had to give my students an image of the world. It is a narrative of the world that was relatively equal 500 years ago and then diverged. First European colonial dominance, then technology. Now we are living in a converging world. So I thought how do I make this graphic, and what if I make them move? And that’s when my son sent an e-mail to me saying “I don’t want to do this dreadful exam paper in history. If I make that animated graph that you want is that OK with you Dad?” He made a first prototype of this moving bubble graph in Dec. 1989. It was a killer graph. We could show a diverging world and a converging world. We could overlay historical developments.

So my son dropped out of university and he gave up his idea of art school and his wife joined him and they spent one year and wrote code, then a second version of it, then we got funding, they employed some more people, we wrote the third version of the code, and the World Health Organization became interested. They were concerned of a conflict of interest working with my children so we couldn’t get some grants, and at some point we had to make the decision to die rich or happy, and we decided to die happy, so we left the commercial interest of it. You want to protect it, but the Gapminder Foundation was a non-profit and became the owner of the software. Commercial companies are a good construct when you want to develop technology, but they’re not good when you want to deal with WHO, UN, and public institutions. Foundations are quite useful for all that and they are independent of the government. And then we did the fourth version and my lectures started to be more and more popular.

We didn’t know where this was going. We thought we would get the UN and World Bank to change their policy because we had this wonderful data about world health indicators. But, international organizations are not managed by their directors and Boards, they are run by the upper-mid level management. And the national states are not managing the United Nations in the interest of the world, because they are fulfilling the interest of their nations. My conclusion is there is extremely weak global governance.

RR: Do you have any examples of how Gapminder has concretely induced Advocacy?

Bubbles for Billions
HR: Bill and Melinda Gates said in an interview with the Wall Street Journal [in 2008 before speaking at the Davos Forum] that there were two things that convinced them to add billions to global health.  One was a good book [Dr. Rosling’s global health textbook] and the other was my video from TED. The whole MDG’s is advocacy. Some people will say “I think this and this is bad, so I want advocacy for it. So I need some graphics and I need some numbers. And then advocate for that.” Make it graphically. And then we’ll advocate for it. 

No Number No Bubble!
Al Gore contacted me and we had two meetings. He got excited about how he would show the whole climate change thing and carbon dioxide levels. “But we don’t have data for all that” I would tell him. He replied “Yeah but we can make a Gapminder.” But we had no data.  I had to be harsh with him and say “Mr. Vice President, No Number No Bubble!”

RR: No Data No Bubble. What about for indicators where it’s hard to get data such as human rights? How do we develop better metrics?

Human Rights: Arguing without Counting. Where’s the Limit?
HR: Health is a question of budgets and policies and regulations. Human rights and health is good on Sunday but not so much on Monday. On Monday you need a bloody budget. And a lot of the human rights discussion has avoided that critical point. Human rights has claimed we should provide free anti-retroviral treatment for everyone who’s infected. But that’s impossible. It’s not difficult, it’s impossible.  You can’t go to a low-income country with 20% prevalence and say that you’re going to treat them for 35 years. Just because you can swim across the British Channel doesn’t mean you can swim across the Atlantic.  It’s not difficult to swim across the Atlantic, it’s impossible, and everyone will drown . . . . This is what we’re seeing, a more realistic approach for countries with a low prevalence rate.  India has one at a national level. They can make a humanitarian decision. Brazil can do it with 0.7% prevalence. But you can’t do it with 20%, it’s unsustainable.

Human rights has taken the global discussion to argue for things without counting.  There’s no such thing as the human right to access health care.  It’s about the level. You must decide, “‘is this a human right?’” Are glasses a human right? There’s no organization in the world promoting the right to glasses and yet it’s a major problem in the world.  Is measles vaccination a human right? Yes I would agree but we have to decide what is the budget. Is free cochlear implant a human right? My youngest grandchild got pneumococcal meningitis when he was one and a half years old and he got completely deaf within twenty-four hours.  He lived in Sweden, and he got cochlear implants, and now he speaks fluent English and Swedish.  That’s because he grew up with the right passport.  No one argues that everyone has the right to cochlear implants so where’s the limit? We have to set a limit otherwise it has no meaning.  It’s too simplistic to argue there’s a human right for this and a human right for that.

I see a very new situation emerging in middle-income countries. In India, 400 million people live with $7 dollars per day and they have the disease panorama of Britain one to three generations ago. And we have great technology today, but the Indian budget is like 100 years ago. So how are we going to use 2010 technology with a 1910 budget on a 1980 disease panorama? . . . . The United States doesn’t have human rights. There’s 20 million who don’t have health care and even the rich people in the US face limits when they can’t get cancer treatment any longer.  To me it’s very difficult: there’s the advocacy way, but when you get into a managerial position it’s different.

RR: Over the next 20 years what will be the major challenges for global health inequity and how should they be addressed? 

Towards a Rational Regulated Market
HR: I think we can have a more rational system when it comes to, for instance, new drugs, which can be used for hemophilia, for cancer, and so on.  It doesn’t make sense that we have a patent for 20 years and only people who can pay can access the drug. It doesn’t make sense . . . . We need to have a several-tiered system. Big Pharma is changing. I was lecturing to the leadership of Pfizer. They asked me to take the 250 leading people in Pfizer and teach them about the world and they are now having emerging markets. They are going to price their new drugs to the Indian success level, because otherwise they use another brand. Brand is more important than patent in the long run. . . . We have to handle the world in a more rational way.

I don’t want less market forces involved, I want more market forces, but I want them within a regulatory framework, which is rational for the world.  I want to reward good research, but I also want to reward those who can synthesize something. Look at the lens in India. Some people are good at making plastic at a very high quality for a very low price that is efficient and then you have good eye surgeons and suddenly you can address cataracts on a national level.  There’s more the private sector can contribute.

Doctors Without Heads
We need to analyze it. Advocacy is nice, but advocacy has to go with a brain. I was the initiator of Médecins Sans Frontières/Doctors Without Borders in Sweden and now I call them Médecins Sans Têtes/Doctors Without Heads because they run advocacy instead of analyzing the business models that work. We have to let those Pharma companies work but we have to regulate them so there is no re-exportation . . . . Pharma says all drugs should be priced according to GDP per capita of the country. I think Microsoft is a very nice company because they put out some Office package and people make pirate copies of it. . . . I know a Vietnamese entrepreneur who made a pirate version of it and I encourage that. Microsoft knows it. If Pharma could only do it the same way. 

Rationally. Count. Use the brain use the heart use the wallet.

RR: How can tools like Gapminder be best used by health professional students around the world?

Helping the Lean Forward Generation Explore
HR: Taking the worldview to get the overall pattern. Because often you read the story about Sri Lanka, or China, but how does this compare to things in Indonesia? With this examination [Gapminder] you get the overall information about what is happening. And that’s quite interesting. You may look at the ratio of literacy, and see that somehow there is an equal ratio of literacy, but then you …see 50% boys and 50% girls can read. That is not the kind of equity you can celebrate, there is terrible poverty equally distributed by the gender of the children. So you can explore it a little more, and some like exploring that, we call them the Lean Forward group they will go into Gapminder World and find their way around. Others are like the Lean Backward group, they take a while.

RR: So Gapminder is a tool that the Lean Forward generation can use…for education, research and activism.

HR: Yes, they can use it! And they can look at so many indicators in an effective way. They cannot find them easily otherwise. It makes it more effective to explore data. But to understand, you should be careful to think you can analyze things by looking at aggregated data, you have to explore the world and look at how it is. . . . You can look at the data in the way you look at the map.

RR: What innovations can we expect from Gapminder in coming years?

Merging Show Business with Information Technology
HR: When I look backwards I am not surprised by what has happened. The only thing I can say is that if you can merge show business with IT technology we can do a lot of amazing things. That’s my main message.

We will try to explain population growth in a way that is understandable. The most common question we get is “Well if you help the poor children survive you’ll destroy the planet”, this is the most common question I get from Swedes. The problem with that is not ethical, the problem  is that it is bloody wrong! When you have 1 child in 3 dying, if you still have 6 children born by father and mother, 4 survive and the population still doubles. There is no way we can control population growth by death. So intuitively we think that child mortality is related to population growth, it’s a happenstance issue…it’s only 2 child families that will stabilize populations and it can be achieved by 2050.

RR: How have you trained yourself to be a storyteller?

Evidence Based Vulgarification
HR: My father and mother told me stories when I was a child and even when I was in primary school I went around and told stories and I could tell stories out of my head to the grandkids. Sometimes you have a sort of gift instead of training. Some people are good at writing, I’m not good at writing, I have more a vocal gift.

I can write scientific papers but that is a way of organizing facts... But writing I’m not so good at. I’m good at talking and what you need is what I call evidence-based vulgrification, it needs to be more vulgar than newspapers, but it needs to be fact-based, (RR: fact-based and attention getting). Yes, simplifying it… look if father and mother have 6 kids and 2 die, then still 4 grow up and in 25 years we have 8 people and in 100 years we have 64 people. It’s something everyone can understand, it’s not religious belief, it’s mathematics. So the only way you can control population growth is either more kids dying or you have less children and they survive! So that is why child survival is one necessary condition for stabilizing the population. So you have to simplify that and use personal empathy. I use lots of personal experiences, it always works.

The presentation has become so formal, people are more formal in their academic performance than in their religion! People go to the podium and use the laser pointers and go to courses for Powerpoint and they learn where to stand and don’t turn your backs on the population.
These are interesting terms… don’t turn your back on the population. I tried to become an actor but I failed utterly, and instead of going into show business I did this as there is almost no competition.

RR: What is your advice to the next generation of young health professionals as we move forward in a word with a lot of data that’s not being using properly? What is your message to our generation about what we can do?

Reducing Maternal Mortality: Who Should Get the Check?
HR: We need a higher proportion of people who do seriously analytical work on how to rationally address the global health situation. We already have a lot of advocacy.  But advocacy will only work if we succeed in what we are doing, and that means more analytical work. 

Reducing maternal mortality is a typical example.  We already have a lot of support for that.  There’s just two things we need to know.  How much does it cost and to whom should we send the check? Should we send the check to the minister of health so the public health service provides free delivery and free cesareans?  Or, should we send the check to non-governmental organizations functioning as a parallel health insurance, paying for delivery services and cesareans.  These are two completely different options: one is the Swedish model, the other is the U.S. model. 

In many countries it is very difficult to make the public health system perform that way, and maybe they should provide it in the parallel system.  We have to analyze the costs, because you never calculate for these costs, you just talk about how important it is that women have these rights.  In the world today, we have as many women dying from major infectious diseases as are dying from complications of pregnancy, and almost the same amount dying in traffic accidents. 

The Heart and the Brain

Stop thinking of the developing world as one. Chile and Somalia don’t belong in the same category, they are two completely different countries.  The distance between them corresponds to 200 years of Sweden’s development.  In the history of the United States, you have to differentiate between the Mayflower, Washington, Lincoln, Eisenhower and Obama.  Those are different stages in the progress of the United States economically, socially, and health-wise.  We can’t discuss what to do in developing countries with this or that.  Somalia, Chad, and Congo are completely different from Ghana, Tanzania, and Kenya.  And then middle income countries like Vietnam and Malaysia are in another situation.  And then upper middle income countries like Mexico and Brazil, they are in yet another category.  Look at the different levels, and then try to analyze what works.

Sweeping advocacy is good: we need to have it at the base.  Someone said, “The urge for justice and the humanitarian feelings have to get us started, but its analytical work that gets us serious.”  We have to get started, then we have to get serious. 

So this is my advice: involve both the heart and the brain.

RR: Who are your heroes?

The Rockefeller of Africa
HR: The man who started Sudatel Telecom Group. Trained in Alexandria, started his enterprise in Britain, moved to roll out the cell phone system in the poorest countries of sub-Saharan Africa.  He earned $3 million U.S. dollars, then started a foundation to promote good African leadership.  He’s the Rockefeller of Africa.

I could make the list quite long like this.  Those people who have reached the global level from origins in lower-middle income countries impress me.  They can understand the background of deep poverty.

And then of course Lula de Silva, the president of Brazil, who I heard speak.  He praised Adam Smith and the market economy and criticized Bush and Sarkozy for not honoring free trade.  He’s lead a major Latin American country to become a growing economy and a socially decent country at the same time. 

On a completely different level, I have a deep respect for the rural, small-scale farmers in Africa, women who I worked with in my research.  I thought I was going to do research with poor rural women and teach them things. But after five to ten years I understood in which direction the learning was going, how skilled they were to survive and bring up their kids in poverty.  You can’t get out of poverty as an individual, it has to be a society.  Individuals fall back in the most dreadful, unpredicted ways.  I had the privilege to work with these extremely knowledgeable persons who work in the poorest countries.

My interest in working in Africa started over the urge for justice and an interest in the rights for people, but in the end it became an intellectual challenge to understand how to raise Mozambique to the level of Ghana, and Ghana to Egypt, and Egypt to Malaysia.  Without economic growth there’s no electricity, there’s no CNN.  You like the market economy but also have to respect highly functioning governments.  So I like good governments with a good corporate sector and a vibrant society.  When they work together I see countries moving very fastly.