by Hans Rosling
Numbers Are Not the Single Solution
I don’t love numbers. I am a huge, huge fan of data, but I don’t love it. It has its limits. I love data only when it helps me to understand the reality behind the numbers, i.e., people’s lives. In my research, I have needed the data to test my hypotheses, but the hypotheses themselves often emerged from talking to, listening to, and observing people. Though we absolutely need numbers to understand the world, we should be highly skeptical about conclusions derived purely from number crunching.
The prime minister of Mozambique from 1994 to 2004, Pascoal Mocumbi, visited Stockholm in 2002 and told me that his country was making great economic progress. I asked him how he knew; after all, the quality of the economic statistics in Mozambique was probably not very good. Had he looked at GDP per capita?
“I do look at those figures,” he said. “but they are not so accurate. So I have also made it a habit to watch the marches on May first every year. They are a popular tradition in our country. And I look at people’s feet, and what kind of shoes they have. I know that people do their best to look good on that day. I know that they cannot borrow their friend’s shoes, because their friend will be out marching too. So I look. And I can see if they walk barefoot, or if they have bad shoes, or if they have good shoes. And I can compare what I see with what I saw last year.
“Also, when I travel across the country, I look at the construction going on. If the grass is growing over new foundations, that is bad. But if they keep putting new bricks on, then I know people have money to invest, not just to consume day to day.”
A wise prime minister looks at the numbers, but not only at the numbers.
And of course some of the most valued and important aspects of human development cannot be measured in numbers at all. We can estimate suffering from disease using numbers. We can measure improvements in material living conditions using numbers. But the end goal of economic growth is individual freedom and culture, and these values are difficult to capture with numbers. The idea of measuring human progress in numbers seems completely bizarre to many people. I often agree. The numbers will never tell the full story of what life on Earth is all about.
The world cannot be understood without numbers. But the world cannot be understood with numbers alone.
Medicine Is Not the Single Solution
Medical professionals can become very single-minded about medicine, or even a particular kind of medicine.
In the 1950s, a Danish public health doctor, Halfdan Mahler, suggested to the World Health Organization a way to eradicate tuberculosis. His project sent small buses with X-ray machines trundling around villages in India. It was a simple idea: eradicate one disease, and it’s gone. The plan was to X-ray the whole population, find those with TB, and treat them. But it failed because the people got angry. They all had tons of urgent health problems, and finally here was a bus with nurses and doctors. But instead of fixing a broken bone, or giving fluids for diarrhea, or helping a woman in childbirth, they wanted to X-ray everyone for a disease they had never heard of.
Out of the failure of this attempt to eradicate one single disease came the insight that, instead of fighting this disease or that disease, it is wiser to provide and gradually improve primary health care for all.
In another part of the medical world, the profits of Big Pharma companies have been dropping. Most of them are fixated on developing a new, revolutionary, life-prolonging medicine. I try to persuade them that the next big boost in world life expectancy (and their profits) will probably come not from a pharmacological breakthrough but from a business model breakthrough. Big Pharma is currently failing to reach huge markets in countries on Levels 2 and 3, where hundreds of millions of people, like the diabetes patient we met in Kerala, need drugs that have already been discovered, but at more reasonable prices. If the pharmaceutical companies were better at adjusting their prices for different countries and different customers, they could make their next fortune with what they already have.
Experts in maternal mortality who understand the point about hammers and nails can see that the most valuable intervention for saving the lives of the poorest mothers is not training more local nurses to perform C-sections, or better treatment of severe bleeding or infections, but the availability of transport to the local hospital. The hospitals were of limited use if women could not reach them: if there were no ambulances, or no roads for the ambulances to travel on. Similarly, educators know that it is often the availability of electricity rather than more textbooks or even more teachers in the classroom that has the most impact on learning, as students can do their homework after sunset.
Where Gynecologists Never Put Their Fingers
I was talking to some gynecologists whose job it was to collect data about sexually transmitted diseases in poor communities. These professionals were ready to put their fingers anywhere on people, and to ask them all kinds of questions about their sexual activities. I was interested to know whether some STDs were more common in some income groups, and so I asked them to include a question about income on their forms. They looked at me and said, “What? You can’t ask people about their incomes. That is an extremely private question.” The one place they didn’t want to put their fingers was in people’s wallets.
Some years later, I met the team at the World Bank who organized the global income surveys and I asked them to include questions about sexual activity in their survey. I was still wondering about any relationships between sexual behavior and income levels. Their reaction was more or less the same. They were happy to ask people all kinds of questions about their income, the black market, and so on. But sex? Absolutely not.
It’s strange where people end up drawing their lines and how well behaved they feel if they stay inside their boxes.
The Ideologues
A big idea can unite people like nothing else and allow us to build the society of our dreams. Ideology has given us liberal democracy and public health insurance.
But ideologues can become just as fixated as experts and activists on their one idea or one solution, with even more harmful outcomes.
The absurd consequences of focusing fanatically on a single idea, like free markets or equality, instead of on measuring performance and doing what works are obvious to anyone who spends much time looking at the realities of life in Cuba and the United States.
Cuba: The Healthiest of the Poor
I spent some time in Cuba in 1993, investigating a devastating epidemic that was affecting 40,000 people. I had several encounters with President Fidel Castro himself, and I met many skilled, highly educated, and dedicated professionals at the Ministry of Health doing their best within an inflexible and oppressive system. Having lived and worked in a communist country (Mozambique), I went to Cuba with great curiosity but no romantic ideas whatsoever, and I didn’t develop any while I was there.
I could tell you countless stories of the nonsense I saw in Cuba: the local moonshine, a toxic fluorescent concoction brewed inside TV tubes using water, sugar, and babies’ poopy diapers to provide the yeast required for fermentation; the hotels that hadn’t planned for any guests and so had no food, a problem we solved by driving to an old people’s home and eating their leftovers from the standard adult food rations; my Cuban colleague who knew his children would be expelled from university if he sent a Christmas card to his cousin in Miami; the fact that I had to explain my research methods to Fidel Castro personally to get approval. I will restrain myself and just tell you why I was there and what I discovered.
In late 1991, the poor farmers in the tobacco-growing province of Pinar del Río had started to go color blind and then experience neurological problems with a loss of feeling in the arms and legs. Cuban epidemiologists had investigated and were now seeking outside help. Since the Soviet Union had just collapsed, no help could come from that direction, and in searching the literature for the few researchers in the world with experience of neurological pandemics among poor farmers, they hit on
me. Conchita Huergo, a member of the Cuban politburo, met me at the airport, and on my first day Fidel himself appeared, accompanied by armed guards, to check me over. His black sneakers squeaked on the cement floor as he circled round me.
I spent three months investigating. I concluded that the poor farmers were suffering not from a mass poisoning from black market food (as rumor had it), nor from some germ causing metabolic problems, but from simple nutritional deficiency caused by global macroeconomics. The Soviet boats that had until recently been arriving full of potatoes and leaving full of Cuban sugar and cigars had not come this year. All food was strictly rationed. The people had given what little nutritious food they had to the children, the pregnant, and the old, and the heroic adults had eaten only rice and sugar. I presented this all as carefully as I could because the clear implication was that government planning had failed to provide enough food for its people. The planned economy had failed. I was thanked and sent home.
One year later I was invited back to Havana to give a presentation to the Ministry of Health on “Health in Cuba in a Global Perspective.” The Cuban government had by this point, with the help of the Venezuelan government, regained the ability to feed the Cuban people.
I showed them Cuba’s special position on my health and wealth bubble chart. It had a child survival rate as high as that of the United States, on only one-quarter of the income. The minister of health jumped onstage directly after I had finished and summarized my message. “We Cubans are the healthiest of the poor,” he said. There was a big round of applause and that turned out to be the end of the session.
However, that was not the message that everyone had taken from my presentation. As I moved toward the refreshments, a young man gently grabbed my arm. He softly dragged me out of the flow of the crowd, explaining that he worked with health statistics. Then he leaned his head close to mine and with his mouth close to my ear he courageously whispered, “Your data is correct but the conclusion of the minister is completely wrong.” He looked at me as if it were a quiz, then answered his own question. “We are not the healthiest of the poor, we are the poorest of the healthy.”
He let go of my arm and swiftly walked away, smiling. Of course, he was right. The Cuban minister had described things from the government’s single-minded perspective, but there was also another way of looking at things. Why be pleased with being the healthiest of the poor? Don’t the Cuban people deserve to be as rich, and as free, as those in other healthy states?
The United States: The Sickest of the Rich
Which brings us to the United States. Just as Cuba is the poorest of the healthy because of its commitment to a single idea, the United States is the sickest of the rich.
Ideologues will invite you to contrast the United States with Cuba. They will insist you must be for one or the other. If you would prefer to live in the United States than in Cuba, they say, then you must reject everything the government does in Cuba, and you must support what Cuba’s government rejects—the free market. To be clear, I would definitely prefer to live in the United States than in Cuba, but I don’t find it helpful to think like this. It is single-minded and very misleading. If it is being ambitious, the United States should seek to compare itself not to Cuba, a communist country on Level 3, but to other capitalist countries on Level 4. If US politicians want to make fact-based decisions, they should be driven not by ideology but by the numbers. And if I were to choose where to live, I would choose based not on ideology but on what a country delivers to its people.
The United States spends more than twice as much per capita on health care as other capitalist countries on Level 4—around $9,400 compared to around $3,600—and for that money its citizens can expect lives that are three years shorter. The United States spends more per capita on health care than any other country in the world, but 39 countries have longer life expectancies.
Instead of comparing themselves with extreme socialist regimes, US citizens should be asking why they cannot achieve the same levels of health, for the same cost, as other capitalist countries that have similar resources. The answer is not difficult, by the way: it is the absence of the basic public health insurance that citizens of most other countries on Level 4 take for granted. Under the current US system, rich, insured patients visit doctors more than they need, running up costs, while poor patients cannot afford even simple, inexpensive treatments and die younger than they should. Doctors spend time that could be used to save lives or treat illness providing unnecessary, meaningless care. What a tragic waste of physician time.
Actually, to be completely accurate I should say that there is a small number of rich countries with life expectancies as low as that in the United States: the rich Gulf states of Oman, Saudi Arabia, Bahrain, United Arab Emirates, and Kuwait. But these states have a very different history. Until the 1960s when they really started getting rich on oil, their populations were poor and illiterate. Their health systems have been built in just two generations. Unlike the United States, these states are not constrained by a suspicion of anything governmental and I would not be surprised if within a couple of years they all had higher life expectancies than the United States. Perhaps the United States will then be less reluctant to learn from them than it is to learn from Western European countries.
The communist system in Cuba is an example of the danger of getting hooked on a single perspective: the seemingly reasonable but actually bizarre idea that a central government can solve all its people’s problems. I can understand why people looking at Cuba and its inefficiencies, poverty, and lack of freedom would decide that governments should never be allowed to plan societies.
The health-care system in the United States is also suffering from the single-perspective mind-set: the seemingly reasonable but actually bizarre idea that the market can solve all a nation’s problems. I can understand why people looking at the United States and its inequalities and health-care outcomes would decide that private markets and competition should never be allowed anywhere near the delivery of public goods.
As with most discussions about the private versus the public sector, the answer is not either/or. It is case-by-case, and it is both. The challenge is to find the right balance between regulation and freedom.
Even Democracy Is Not the Single Solution
This is risky, but I am going to argue it anyway. I strongly believe that liberal democracy is the best way to run a country. People like me, who believe this, are often tempted to argue that democracy leads to, or is even a requirement for, other good things, like peace, social progress, health improvements, and economic growth. But here’s the thing, and it is hard to accept: the evidence does not support this stance.
Most countries that make great economic and social progress are not democracies. South Korea moved from Level 1 to Level 3 faster than any country had ever done (without finding oil), all the time as a military dictatorship. Of the ten countries with the fastest economic growth in 2016, nine of them score low on democracy.
Anyone who claims that democracy is a necessity for economic growth and health improvements will risk getting contradicted by reality. It’s better to argue for democracy as a goal in itself instead of as a superior means to other goals we like.
There is no single measure—not GDP per capita, not child mortality (as in Cuba), not individual freedom (as in the United States), not even democracy—whose improvement will guarantee improvements in all the others. There is no single indicator through which we can measure the progress of a nation. Reality is just more complicated than that.
The world cannot be understood without numbers, nor through numbers alone. A country cannot function without a government, but the government cannot solve every problem. Neither the public sector nor the private sector is always the answer. No single measure of a good society can drive every other aspect of its development. It’s not either/or. It’s both and it’s case-by-case.
Factfulness
Factfulness is … recognizing that a sing
le perspective can limit your imagination, and remembering that it is better to look at problems from many angles to get a more accurate understanding and find practical solutions.
To control the single perspective instinct, get a toolbox, not a hammer.
• Test your ideas. Don’t only collect examples that show how excellent your favorite ideas are. Have people who disagree with you test your ideas and find their weaknesses.
• Limited expertise. Don’t claim expertise beyond your field: be humble about what you don’t know. Be aware too of the limits of the expertise of others.
• Hammers and nails. If you are good with a tool, you may want to use it too often. If you have analyzed a problem in depth, you can end up exaggerating the importance of that problem or of your solution. Remember that no one tool is good for everything. If your favorite idea is a hammer, look for colleagues with screwdrivers, wrenches, and tape measures. Be open to ideas from other fields.
• Numbers, but not only numbers. The world cannot be understood without numbers, and it cannot be understood with numbers alone. Love numbers for what they tell you about real lives.
• Beware of simple ideas and simple solutions. History is full of visionaries who used simple utopian visions to justify terrible actions. Welcome complexity. Combine ideas. Compromise. Solve problems on a case-by-case basis.
CHAPTER NINE
THE BLAME INSTINCT
About magic washing machines and money-making robots