Hans Rosling on Why We Should Care About Global Health

By Gustav Drevin

MY FIRST MEETING WITH PROFESSOR Hans Rosling included a nervous handshake and a stuttering “You are such a source of inspiration.” He answered by reflex: “Well, I hope someday I become a source of knowledge.” I walked away, silenced. Embarrassed. Ashamed even. I had become a groupie. He does not desire a rock-star status. He is a statistician; a scientist. Fortunately, he did not hold our first meeting against me when we, a few weeks later, spoke on the phone. During what became a one-sided, half-hour lecture on everything from apathetic child refugees to the Uygur in China, one question in particular stuck with me as he talked about global health and Karolinska: “Är det enda målet med läkarprogrammet att utbilda studenter inför svensk AT?” In other words, what is the aim of Swedish medical school, or any programme at Karolinska? The only aim of medical school cannot be training students for Swedish internships.

Most people know of Rosling through his work in Africa and by his TED talks. Few know as much of his professorship. For instance, he set up the precedent to the Global Health elective offered at eleven programmes at Karolinska, in the late 1980s at Uppsala University. The course highlights social determinants of health. He brought it to Karolinska in 1996 and it has since been one of the most popular electives, receiving praise and pedagogical prizes. Rosling has travelled with it twice per year for ten years, up to 2006, and has spent 40 working weeks abroadwith students. Thus, he has seen many paradigm shifts among them. It was, not surprisingly, here that the idea to Gapminder Foundation and the Trendalyzer bubble software was born.

He is passionate, but yet not an activist or optimist. He calls himself a ‘possibilist’. Whether speaking to Bill Gates or a star-struck student from Karolinska, he is just as passionate about his subject. At times, it is hard not to feel intimidated by his straightforwardness and energy. He adds “huh?” and “isn’t it?” to many sentences, which witnesses of his stay in Mozambique, where one uses those sort of affirmation-seeking interjections to engage the listener in the conversation. His, at times, playful approach to teaching and pedagogy contrasts the serious messages he delivers, but the two never collide. Instead, the juxtaposition of humour and seriousness enhances the message.

 

Photo by Martin Kjellberg for Medicor

Professor Hans Rosling is most known for his appearances at the TED conferences, where he famously revealed his Trendalyzer software in 2006. Having practised medicine in Mozambique, Rosling started a global understanding course at Uppsala University in the 1980s and helped establish the Swedish branch of Médecins Sans Frontières, Läkare Utan Gränser in 1994. In 1996 he brought his course to Karolinska Institutet, and 80-100 people travel with it every year. With a 7,5% KI employment today, Rosling travels the world to lecture banks, companies, and governments on improvements and shortcomings in the world. Having been praised by the likes of Bill Gates and Al Gore, he is a driving force in the field of international understanding. Time Magazine listed him among the 100 Most Influential People in the world in 2012, together with Barack Obama, China’s President, Xi JinPing, and Brazil’s President, Dilma Rousseff.

The Global Health elective has opened the eyes of thousands of students at Karolinska. Ironically, one seems to learn more about one’s own life when experiencing that of those less privileged. “One thing the students said was ‘damn, now I understand Swedish healthcare!’ They had not understood that somebody has to pay for ambulances,” Rosling says. “You understood health economics when you saw a much more meagre system, and what the price was.” The course was an immediate success and more countries were added to the list. “It was like going up Kaknästornet: ‘Aha! Now I see Stockholm!’”

Class discussions intensified and deepened when the students came home and began to regard healthcare from another angle. “We got a very good perspective on the course /…/ as students went to different places, India, Africa, Cuba, Iran, and then talked among themselves.” The elective helped broaden the students’ view of the profession and improved the quality of their education. Rosling acknowledges that it would not be the same if the course were taught only via books and lectures. “I call it experience-based knowledge.” He adds that it would be useful to have a course early in the education as it expands students’ view on high-income-country healthcare. He also notes that this international awareness benefits the pharmaceutical industry, international relations, and the struggle against antibiotics resistance.

It was important that students realised that there are brilliant colleagues outside of Sweden and that resource scarcity certainly does not entail incompetence. On the contrary, Karolinska invited foreign physicians to train students in their clinical skills. Because, “in Sweden, you do not examine patients – you send them on to the X-ray department.” He truly emphasises that we must respect our foreign colleagues and that resource limits mean nothing when it comes to skills. “We came to India and went on rounds. Sixty patients, four rows, fifteen beds in each. And then there were these brilliant doctors who read The Lancet on Saturday and knew everything. And nurses, taking pulse and blood pressure of all patients in a way that never worked in Sweden. ‘Such skilled people – and such a bad hospital?’” He puts on a big smile that reflects the absurdity of these prejudices. He knows what he talks about since he was prejudiced himself, as a young student studying in Bangalore, India. “It took me 30 minutes to realise that from being in the top quartile of the class [in Sweden], I was in the bottom quartile. They read thicker books, more often, than we did.”

Rosling indicates that many assume that affluence automatically makes you better than a colleague from a poorer country. “People still have a bloody Tintin attitude towards colleagues from other countries”, he says and gives the example of students asking a midwife in Tanzania if she trained her daughter in the same profession. What follows is a miniature monologue with gestures and a dramatic voice as he enters the role of the Tanzanian woman: “‘My daughter? A midwife? Never! I have fought all my life so that she can attend high school and now she has a job in front of a computer in Dar Es-Salaam. Do you think I am stupid?!’”

If you ask Rosling, it is not that we necessarily think of ourselves as better, but that we romanticise about poverty as something making people appreciate other aspects of life more. Rosling’s famous TED talks dealing with everybody’s right to a washing machine and the sandal-to-aeroplane comparison strike the same point. This is important for us to understand, since we are to reconcile the, at times, conflicting ends of development and sustainability in future international debates. One argument cannot be that poverty is something advantageous. Hans Rosling has too often encountered this. “I call it a toxic combination of arrogance and ignorance.”

There is a risk of romanticising in the opposite direction, too. During the Global Health – Beyond 2015 conference, Richard Horton (editor-in-chief of The Lancet) pulled down a wave of applause with his endnote speech where he said that although he has flirted with both “Marxism” and “God”, he considers global health his life philosophy. Rosling, who seemed to have intense discussions with Horton between the sessions, argues that this is wrong. One should not put this field on a pedestal because one feels sorry for the world. “I loathe his attitude, that it is his ‘philosophy’. I feel a damned disgust toward that attitude to global health. I was about to cry out ‘Hallelujah’ in the end.”

Just as I had said that he was a source of inspiration, Horton’s almost religious approach to the field bothers Rosling. “I want it to be an academic subject. It should not be made an ideology. You should simply know how things are. I have become very humble to that, simple knowledge.”

However, acquiring knowledge and insight is not simple. The gaps in knowledge still exist. They have only marginally decreased, as Rosling shows in a complementary ‘unethical study’ chart” he compiled earlier this spring on students’ knowledge of international differences in child mortality. “These misconceptions of the world remain. Obviously, students are not taught the right things in school.” Hence, the Global Health elective at our university holds relevance and importance. Especially so, as we get richer while the extremely poor two billion still try to lead their lives on less than two dollars per day. “It becomes increasingly difficult by each decade to comprehend extreme poverty and resource scarcity.”

Extreme inequalities still exist. And grow. All of this is made more comprehensible if you have been in these settings. It is difficult to get the larger picture from high-income countries, since we enjoy such a high standard of living.

 

 

 

EXTREME AFFLUENCE AND EXTREME POVERTY                            There are seven billion people on Earth. One billion are rich (blue). Four billion are in the middle of the scale (yellow). Two billion are extremely poor (red). While Sweden consider the titanium hip transplant a human right, the extremely poor will have little resources but e.g. the wooden Pinard horn that since the 19th century has been used to listen to the foetus’ heartbeat through the abdomen and uterus of the mother. In the middle three billion, the main problem is to prevent noncommunicable diseases (NCDs), such as lung cancer from smoking. The black bricks show millions of children dead before their fifth birthday per year. Six out of the seven million children aged under-5 dying each year are born into the poorest two billion.  (Photo by Martin Kjellberg for Medicor)

He jokes that while in many countries no analgesics can be afforded for performing abortions, it would be scandalous in Sweden if you would not apply numbing cream when taking blood pressure. While some countries afford the €8,000 titanium hip implant, many countries still use the primitive Pinard horn, instead of the ultrasound, to do prenatal health checks [see our front cover/featured photo].

“[Swedish] healthcare is so well-organised that it constantly gets harder to understand resource scarcity.” Something that followed this, he remarks, was that students had problems with that resource scarcity meant spending less time with patients. Some students were offended, as if the behaviour towards the patients were badly intended. “I have noticed this through the years: you have greater and greater expectations of how to behave toward patients. You are not used to working under tough pressure.”

But, the Global Health elective teaching this is on the verge of atrophying. Following an administrative reform a few years back, the course is today double-charged. It pays for facilities even during weeks when students travel to their respective universities abroad. Rosling implies that prefects, who are given insufficient budgets, use this loophole to strengthen their economies.

It is not the prefects’ fault. Still, the new reform ventures the future of the elective. “We have run this course for fifteen years, a hundred students every year, and now it is going to hell because of double taxation. To even call it ‘double taxation’ would be putting it nicely. To be honest, it is gangster protection money.” There is a justified disappointment in his voice. The course is one of the most appreciated at our university and is invaluable not primarily for the medical education, but for students’ personal edification. He brought it himself to Karolinska 17 years ago. Now it may fall apart.

Rosling is doubtful that it is an easily resolved problem and his frustration is palpable. “It is ridiculous! It is beyond my wildest imagination that I would be lecturing the world’s leading banks. UBS in Switzerland and Goldman Sachs in Manhattan. I give lectures to their boards about the development of the world. That is easier – to be one of Time Magazine’s 100 Most Influential People in the world is easier – than to get an honest economy for [the] global health [course] at KI.” We ask how far it can continue. “They are killing the course! It is so rank that it is without parallel! When will you give up if I strangle you?!” He bounces up from his chair, grabs the tie of our photographer, and pulls it like a snare. Laughter ensues. Again, a light approach with a heavy message.

Although the noose tightens, Rosling notes that the course does not demand more money. Only a fair price for the services it uses. It would be unworthy a university of the Karolinska Institute’s stature and reputation to cancel one of its most popular courses. The Global Health Department at Karolinska (IHCAR) even considers the course its flagship. Since the problems result from an administrative change that the university has brought upon itself, it is embarrassing that this problem exists to begin with.

As one of the leading forces in the field, it would be interesting to see what Rosling would do if he were the president of Karolinska. He acknowledges that he likes the three recent presidents very much. “Hans Wigzell (1995-2003) reformed KI in a very nice way, almost like a new crush. He gave us a more dynamic system where money went to those who performed. Harriet (Wallberg-Henriksson, 2003-2013) took over that system, but a crush is always easier than a marriage. A crush is good, it is before you have to decide who takes out the trash and who defrosts the freezer. But, after three or four years a marriage becomes a bit boring. Harriet had to take care of that.” The new president, Anders Hamsten, has said he will focus more on education and give professors increased freedom. Rosling declares his hope in that Hamsten will keep his word.

Additionally, Rosling argues that a university reaches a high standard only if individual researchers and teachers are allowed to form their own research and teaching. Only then, the teaching becomes interesting to students. “You cannot come dragging along with something that you say is so very important, and then, when you teach, it is so boring that students fall asleep.” After all, electives such as this must be driven by “its own force, motivation, and quality of the education,” he states, so “that it gets the students to say that this is where they want their money to go.”

He would give students a short but intense introduction to international health early in our programmes. “It is better to let them attend the course early in their training, because, later you ask the right questions.” Of course, the quality of these few days of global health should be of a high standard. “Give them two days and make them so good that the students demand more. New education must be driven by that students say ‘this was relevant, this was exciting, this was interesting, we want more.’”

Now, why bother? Many will end up practising their profession in Sweden for their whole careers. The majority of us, in fact. Why should we care about child mortality in Bangladesh or drug-resistance in the Ukraine?  “There is not only a northern sky, there is also a southern sky. You do not see it from Sweden, but there are comets there too. Geologists study volcanoes, although there are none in Sweden. Why would they do that? They are geologists in Sweden, why study volcanoes?” Medical professionals owe it to the universality of medicine and to the human condition to know that there is a wide range of variances in the world. We must be humble toward these transformations and not forget what goes on around us. “Since we are very different from the rest of the world, we have to keep contact with the realities in these parts of the world.”

There is much to learn from our colleagues in other countries and even more from experiencing healthcare and social settings different from our own. Although not all wisdom can be quantified in coloured bubbles, we should be attentive as to how the world develops. It is not only a responsibility toward our future patients but also to ourselves as human beings accountable for what happens at our planet. It will be most relevant in our careers and lives to update ourselves constantly. Because, the changes going on in the world are of immense gravity. According to Professor Hans Rosling, so large that we do not even realise it. “It is not globalisation that we are witnessing now. This is not even the beginning of globalisation. This is just the end of the non-globalised world.” •

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The course administration responds to the criticism

The course administrator at the Global Health Department (IHCAR), Anna Mia Ekström, says that money is a problem, but also the only problem she knows of. “The funding problem is caused by indirect costs (INDI), which is an overhead cost that institutions and the central administration adds on to the course.” Decision-making lies not with the course administration, although it, together with the prefects, considers alternatives. It works hard at creating a funding plan or bringing about a revision of INDI so that the loophole goes away. The Dean of Education, Jan-Olov Höög, confirms that “there are no plans to cancel the course”

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