by Hans Rosling
I had heard that a South African submarine had surfaced in seas near Cava. Had the desperate apartheid regime attacked us with biological weapons? I carried on investigating patients but my dread of my own paralysis, perhaps death, was haranguing me loudly.
“Get out of here!” said my fear. “Report what you have seen and let proper experts take the risks of investigating this.”
The intense arguing inside my head was unceasing.
“No, stay. It’s your professional duty to collect as much information as possible and to do it now. If this epidemic is to be halted it will depend on what you do today.”
And then: “Come on, I’m a foreign doctor. I came here to practice. I didn’t sign up to expose myself to unknown, dangerous and probably infectious diseases. Sorry, that’s the long and the short of it: I’m not working for a humanitarian organization. I’m a jobbing doctor employed in the region’s regular healthcare system. As per my contract.”
I struggled to keep my fears under control. In the middle of my ongoing internal debate, which was growing increasingly dramatic, Mama Lucia called me inside for lunch.
“No time for lunch,” I replied rudely.
She didn’t accept being dismissed, and drew herself up, hands on hips.
“Yes, there is,” Mama Lucia said steadily. “You have the time. Whatever else happens here in Cava, at twelve o’clock we meet to pray and eat. If we didn’t, we wouldn’t have endured for twenty years. How long have you been working in Mozambique?”
“Almost two years,” I mumbled.
“So, you’re just a beginner. You should do as I say.”
Something about her made me obey. Her face had a set, serious expression, She never laughed nor did she ever look tired. Mama Lucia was the boss. I might decide what ought to be done but she would decide how.
I pulled off my white coat and washed my hands, as instructed. By my basin there was a clean towel, soap in a clean dish, and a jug of water. Mama Lucia filled the basin. She always kept order around her.
At twelve o’clock precisely, I sat down at the table to eat lunch with the three nuns. It was soothing to listen to Mama Lucia’s long prayer. She was thanking God for my arrival. I did not sense any divine presence but was overcome with respect as I observed the calm of the three nuns—a calm that also began to fill me. At that first lunch with the nuns, I understood the value of taking a break. It is important to have time for contemplation now and then. Perhaps for taking a walk.
During my years in Mozambique I lost weight—I could never get into a balanced rhythm there. Mama Lucia had achieved it though; she was herself, a complete and steady person who appeared free from any doubts about her life’s choices. She had decided and now she was content.
The nuns had offered an entire generation of people in and around Cava education and healthcare. They had stayed throughout the long war of independence and kept their place in the world intact during the difficult years after independence. Mama Lucia, who could speak Makua fluently, had gone back home to Italy just once in twenty-one years. And now, even with a nasty epidemic flaring up on their doorstep, the nuns continued their work with dignity and persistence. Some of their thinking was very practical: they had made walking sticks for the paralyzed, for instance.
* * *
In the quiet moments while Mama Lucia prayed, my sense of responsibility overcame my fear. I asked myself: who am I, a mere passerby and an atheist who believes in evidence, to get twitchy and want to run away after just two hours? If these women have the staying power to keep going in this place for twenty years, surely I can muster the courage to hang on for two days? Precisely as she said “Amen,” I decided to stay and investigate the outbreak until I had found the cause of this grim disease.
Mama Lucia (far right)
During the next few days, streams of patients, most of them carried by relatives, continued to arrive at the nuns’ clinic. When I checked over the summaries of the week-by-week development of the epidemic, my pangs of fear came back: the number of new cases was doubling every week. But it need not be biological warfare. There had been a drought in 1981. People were hungry enough to start eating wild plants. Could the paralysis be due to a combination of poor nutrition and some naturally occurring poison?
I returned to Nacala and discussed the situation with Agneta. Reports of new cases were coming in from more and more villages. We quickly made two decisions. I would have to lead a wide-ranging investigation. My wife and children, on the other hand, were under no obligation to risk contact with a possibly very dangerous virus. They would go to stay with friends in Nampula.
Our agreement gave me a deep sense of satisfaction. If they had stayed, I would have been haunted by unbearable, unceasing anxiety, and work might have been impossible. Agneta explained to the children what a fun time they were going to have and we all helped to pack the car with a month’s stay in mind. Agneta told the children to bring their favorite toys and as the car drove away they all waved bye-bye to me. I so admired her calm and felt relieved. Once the car had rounded the corner of our block and driven out of sight, I no longer needed to worry about infecting the children.
* * *
In principle, the method for investigating a new form of disease is straightforward. You begin by defining the symptoms so that a brief examination is sufficient to determine whether or not a patient has that particular condition. Our set of symptoms was uncomplicated: sudden onset of spastic paralysis in both lower limbs and jerking of the leg and foot in response to taps on the tendons below the knee and at the heel. Other obvious tests came out normal: skin sensitivity was unchanged and there were no indications of other neurological deficits, or illnesses such as tuberculosis affecting the spine.
Patients on crutches in Cava
The next step is to include as many people as possible: during the next few weeks, our target was to examine a population of some 500,000 people from our own district and two neighboring ones. Although the area was one of the poorest in the world, we did not anticipate that this would be too difficult. We sought out the elders in the main twenty-five villages and got their agreement to call on the four to five hundred households per village where someone had suffered obvious problems with walking since the last rainy period.
Working out which kinds of walking difficulty fitted our diagnostic criteria was going to be harder. We selected the best nurses who spoke the local language, and taught them how to carry out the neurological tests. They entered the results into a simple form and every night they would run through their cases with one of us doctors. This would eventually enable us to draw a graph of the spread of the epidemic on the map pinned to the wall in our tiny “war office.”
The biggest challenge was to estimate the age of the patient and the day of the onset of the illness, because people in these villages lived without calendars. The nurses became accustomed to using the local ways of keeping track of time.
But there was an almost unsurmountable problem: how to find the motorbikes and engine fuel needed to transport the nurses into the countryside and back again. Our region had to turn to the provincial authorities to ask for two cars, and ten or more motorbikes with fuel. We also asked for two doctors, ten nurses, and any available experts on neurology and plant poisons; and for temporary healthcare staff to replace us at the clinic while we investigated the outbreak.
Julie Cliff from the Ministry of Health drove off one evening to hand our request to the head of the province’s health service and also to inform the ministry and the World Health Organization in Geneva. Anders Molin and I were left on our own, together with our staff but without any real expectation that the necessary help would arrive any time soon.
* * *
I was alone in my office one early morning. Nothing suggested that this room was the headquarters of an emergency investigation into a suspicious outbreak of what might be biological warfare. I was bent almost double over my small, gray-painted metal desk. The floor was covered in brown
linoleum. On the sandy road that I could see through the grid in my window, people were streaming past. Most of them were women with young children coming to join the growing queues at the hospital’s clinic.
The small hospital in Nacala was located next to a building where the healthcare administration’s office was housed. It was a pompous way of describing an office with three people working in one room: Victor, a secretary, and me. Victor had been a typist during the colonial era who since independence had been promoted to administrative head for the local health service.
That morning I had asked Victor and the secretary to write out the forms designed to be the basis of the investigation. We needed hundreds of copies and we of course had no photocopier. Victor figured out that by using one top sheet and three carbon copies you could get four for the price of one.
All the preparations for our study of this ominous epidemic of paralysis were very practical: as well as the forms, we needed wall space for the map of the districts and the graph of outbreaks that we would update daily with case information. I had managed to get hold of some large sheets of cardboard to stick on one of the walls. It was good to have something tangible to do, because I felt profoundly insecure about the whole project. This gave me an opportunity to be on my own and think.
Will this plan work out at all? I wondered. How many weeks or months would it take for the essential motorbikes to be delivered? Victor had told me that there were no motorbikes for sale in the entire province. All the provincial head of the service could do was to commandeer bikes from other districts and give them to us, infuriating their actual owners. Just that morning, I had been explaining the situation to the political district administrator in Nacala. In his opinion, it was a thoroughly bad idea to investigate the epidemic in the way I was suggesting.
“Your staff will simply bring this damned disease into the town. Better to isolate the villages and wait for the whole thing to die down again.”
He added that rumors of an epidemic were already spreading and people were becoming frightened. He intended to try convincing the governor of the province, situated in Nampula city, that strong-arm tactics should be used to keep the affected rural areas in isolation. To him, his own political career mattered more than the welfare of the local population.
I was becoming increasingly stressed as I pinned up the sheets of cardboard on the wall. I worried that the young Mozambican republic lacked the kind of wise, strong leaders who would be able to procure enough motorbikes for us.
Yet just a few minutes later, I was proved wrong.
The screech of car brakes outside caught my attention. Once the dust had settled, I saw a truck belonging to the Nacala police, and it was jammed full with motorbikes. Two policemen jumped out and started to unload the bikes. This was incredible. Normally, we had to wait for weeks or months to get a single spare part for just one damaged bike. Then I realized that these were not the white-painted vehicles of the public health service. Our town policemen were unloading all sorts of motorbikes, mostly well worn. Feeling dubious, I went outside to ask how they had managed to find so many bikes in a such a short amount of time. A young policeman shrugged and said:
“The governor issued an order. There’s an emergency and you needed motorbikes. Am I right, you wanted ten or so?”
“Yes, I do need them. But how did you get hold of them?”
“Well, the only available motorbikes are the ones on the roads,” he said. “We can flag them down. So, we did. We nationalized them, I guess. Governor’s orders. We had no choice.” The policemen continued unloading the bikes. I could see the Kalashnikovs slung on their backs.
Victor and I had a discussion about what to do next. The Nacala-born Victor recognized the motorbikes and knew who the owners were. We both realized that sooner or later the bikes would be claimed.
It was sooner. Just a brief moment later, the air resounded with desperate cries and shrieks. A group of men came running down the road to the hospital and stopped at the other side of the police truck. It was obvious that they were the owners of the bikes that the police were busy delivering to me. Authoritarian regimes can be efficient but the rulers’ rough-and-ready methods tend not to make for harmonious day-to-day life.
I went to stand between the men and their bikes. I began with a calming reassurance.
“You will get your motorbikes back today.”
One of the men who spoke good Portuguese asked politely if he might explain to me what had happened. They had been stopped on their way to work by armed policemen who had pointed guns at them. Their motorbikes had been taken and loaded onto the police truck. When the men asked why, they had been told that the doctor needed transport and if they objected, they should talk to the doctor.
The bikes were essential means of work for these men. They constituted their income, their savings, and everything they had. To have them taken away was huge. Nacala had forty bike owners and we had just robbed a quarter of them.
“You must listen to me now and do as I ask you,” I said. “You know that there’s an epidemic and it’s coming closer.”
They had all heard of it.
“I am in charge of stopping it. And the police told the truth: I do need motorbikes, but I didn’t know that the police would come and take them away from you. You will get them back today but tomorrow you must come back to the hospital with your bikes. Then you must drive our nurses into the countryside. You are the driver of your own bike. The nurse will be riding behind you.”
Their greatest fear was to be separated from their motorbike. Once they had understood it wouldn’t happen, negotiations could begin.
“What about our jobs?”
I promised that they would be given time off with full pay and asked only to drive their own bikes.
“What about wear and tear?”
“You will be given engine oil.”
My non-negotiable point was that the motorbikes must be used to investigate the epidemic. Their non-negotiable point was that no one except the owner would drive the bike and that the owner would take it home with him every night.
The rest of the agreement took two more hours to negotiate. Over the next few weeks, the motorbike owners would come to the hospital office every morning and set out to a distant village with a nurse riding along behind. I would persuade their bosses that these men should keep their wages. The Ministry of Health would give each one of them a liter of engine oil per week to “show appreciation.” In the planned economy of Mozambique, engine oil was a hard currency, but it was part of state planning to allocate more oil to the hospitals than we could use. We had an excess of oil, of course, because we never had the state-planned number of vehicles.
By that afternoon, two doctors and a group of newly qualified nurses had arrived by minibus. The following day, the provincial health authority sent us a car. Even in the absence of media hype, any society is frightened by an epidemic outbreak of a serious new disease. During these days in August 1981, we were able to use fear as a lever to get the resources we needed to investigate the situation. There was no help on offer from outside Mozambique—not one dollar, not a single expert. Later, I realized that it had been the minister of health, Dr. Pascoal Mocumbi, who had done everything in his power to provide us with what we needed.
In the villages, elders rounded up everyone showing signs of walking problems. The nurses examined every one of them and a doctor went through their results. Data points began to accumulate on my map- and cardboard-covered office wall. The investigation was under way.
Every established case was entered into the data set. When the nurses returned from their motorbike rides, they came straight to my office to give me an account of their day in front of the graphs and maps. Within six weeks, the large team, with the help of local leaders, had examined half a million individuals and identified a total of 1,102 cases of the paralyzing condition. From the information displayed on the board, two unmistakable patterns emerged.
For each case, w
e had carefully determined on which day the disease had manifested, so we knew the time profile of the epidemic: it had reached its peak by the end of August, was declining during September and had been reduced to a very few new cases in October.
Geographically, the outbreak was confined to agricultural areas in the interior, around ten to forty kilometers from the coast. There was not a single case in Nacala or the semi-urban district capitals. The afflicted region lay between the fishing communities along the northern coastline and the fertile highlands with higher rainfall. In fact, the outbreak had occurred in an area that normally saw little rain in summer and early autumn and had had none this year. The drought had killed off maize, peanuts, and beans. Only one type of plant had been worth harvesting and it had saved the local people from starvation: cassava, a staple foodstuff in many regions of southern Africa.
It was also gradually becoming clear that gender and age were significant factors. The disease hit children in particular but none under the age of two. Among the adults, the majority of victims were women.
When it comes to investigating an epidemic, collecting and analyzing the numbers is only half of the job. The most urgent task is to establish whether or not the condition is infectious. We went to extreme lengths to locate even one single outbreak in Nacala. I dispatched staff in civvies to pick up suburban gossip and rumors but they couldn’t find evidence of even one case. After just three weeks, we were able to conclude that the disease was not transmitted by human-to-human contact, because many people from the disease-ridden areas had visited relatives in town, just as townspeople had gone to stay in the countryside during June, July, and August, yet no one in the town had been affected.