Factfulness: Ten Reasons We're Wrong About the World – and Why Things Are Better Than You Think (20 page)

Because “frightening” and “dangerous” are two different things. Something frightening poses a perceived risk. Something dangerous poses a real risk. Paying too much attention to what is frightening rather than what is dangerous—that is, paying too much attention to fear—creates a tragic drainage of energy in the wrong directions. It makes a terrified junior doctor think about nuclear war when he should be treating hypothermia, and it makes whole populations focus on earthquakes and crashing planes and invisible substances when millions are dying from diarrhea and seafloors are becoming underwater deserts. I would like my fear to be focused on the mega dangers of today, and not the dangers from our evolutionary past.

Factfulness is … recognizing when frightening things get our attention,
and remembering that these are not necessarily the most risky. Our natural fears of violence, captivity, and contamination make us systematically overestimate these risks.

To control the fear instinct,
calculate the risks.

When I was a young doctor in Mozambique in the early 1980s, I had to do some very difficult math. The math was difficult because of what I was counting. I was counting dead children. Specifically, I was comparing the number of deaths among children admitted to our hospital in Nacala with the number of children dying in their homes within the district we were supposed to serve.

At that time, Mozambique was the poorest country in the world. In my first year in Nacala district, I was the only doctor for a population of 300,000 people. In my second year, a second doctor joined me. We covered a population that in Sweden would have been served by 100 doctors, and every morning on my way to work I said to myself, “Today I must do the work of 50 doctors.”

We admitted around 1,000 very sick children each year to the district’s one small hospital, which meant around three per day. I will never forget trying to save the lives of those children. All had very severe diseases like diarrhea, pneumonia, and malaria, often complicated by anemia and malnutrition, and despite our best efforts, around one in 20 of them died. That was one child every week, almost all of whom we could have cured if we had had more and better resources and staff.

The care we could provide was rudimentary: water and salt solutions and intramuscular injections. We did not give intravenous drips: the nurses had not yet acquired the skills to administer them and it would have taken up too much of the doctors’ time to place and supervise the infusions. We rarely had oxygen tanks and we had limited capacity for blood transfusions. This was the medicine of extreme poverty.

One weekend, a friend came to stay with us—a Swedish pediatrician who worked in the slightly better hospital in a bigger city 200 miles away. On the Saturday afternoon, I had to go on an emergency call to the hospital and he came with me. When we arrived, we were met by a mother with fear in her eyes. In her arms was her baby who had severe diarrhea and was so weak that she could not breastfeed. I admitted the child, inserted a feeding tube, and ordered that oral rehydration solution should be given through the tube. My pediatrician friend dragged me into the corridor by the arm. He was very upset and angrily challenged the substandard treatment I had prescribed, accusing me of skimping in order to get home for dinner. He wanted me to give the baby an intravenous drip.

I became angry at his lack of understanding. “This is our standard treatment here,” I explained. “It would take me half an hour to get a drip running for this child and then there would be a high risk that the nurse would mess it up. And yes, I do have to get home for dinner sometimes, otherwise my family and I would not last here more than a month.”

My friend couldn’t accept it. He decided to stay at the hospital struggling for hours to get a needle into a tiny vein.

When my colleague finally joined me back at home, the debate continued. “You must do everything you can for every patient who presents at the hospital,” he urged.

“No,” I said. “It is unethical to spend all my time and resources trying to save those who come here. I can save more children if I improve the services outside the hospital. I am responsible for
all
the child deaths in this district: the deaths I do not see just as much as the deaths in front of my eyes.”

My friend disagreed, as do most doctors and perhaps most members of the public. “Your obligation is to do everything for the patients in your care. Your claim that you can save more children elsewhere is just a cruel theoretical guess.” I was very tired. I stopped arguing and went to bed, but the next day I started counting.

Together with my wife, Agneta, who managed the delivery ward, I did the math. We knew that a total of 946 children had been admitted to the hospital that year, almost all of them below the age of five, and of those, 52 (5 percent) had died. We needed to compare that number with the number of child deaths in the whole district.

The child mortality rate of Mozambique was then 26 percent. There was nothing special about Nacala district, so we could use that figure. The child mortality rate is calculated by taking the number of child deaths in a year and dividing it by the number of births in that year.

So if we knew the number of births in the district that year, we could estimate the number of child deaths, using the child mortality rate of 26 percent. The latest census gave us a number for births in the city: roughly 3,000 each year. The population of the district was five times the population of the city, so we estimated there had probably been five times as many births: 15,000. So 26 percent of that number told us that I was responsible for trying to prevent 3,900 child deaths every year, of which 52 happened in the hospital. I was seeing only 1.3 percent of my job.

Now I had a number that supported my gut feeling. Organizing, supporting, and supervising basic community-based health care that could treat diarrhea, pneumonia, and malaria before they became life-threatening would save many more lives than putting drips on terminally ill children in the hospital. It would, I believed, be truly unethical to spend more resources in the hospital before the majority of the population—and the 98.7 percent of dying children who never reached the hospital—had some form of basic health care.

So we worked to train village health workers, to get as many children as possible vaccinated, and to treat the main child killers as early as possible in small health facilities that could be reached even by mothers who had to walk.

This is the cruel calculus of extreme poverty. It felt almost inhuman to look away from an individual dying child in front of me and toward hundreds of anonymous dying children I could not see.

I remember the words of Ingegerd Rooth, who had been working as a missionary nurse in Congo and Tanzania before she became my mentor. She always told me, “In the deepest poverty you should never do anything perfectly. If you do you are stealing resources from where they can be better used.”

Paying too much attention to the individual visible victim rather than to the numbers can lead us to spend all our resources on a fraction of the problem, and therefore save many fewer lives. This principle applies anywhere we are prioritizing scarce resources. It is hard for people to talk about resources when it comes to saving lives, or prolonging or improving them. Doing so is often taken for heartlessness. Yet so long as resources are not infinite—and they never are infinite—it is the most compassionate thing to do to use your brain and work out how to do the most good with what you have.

This chapter is full of data about dead children because saving children’s lives is what I care about most in the whole world. It seems heartless and cruel, I know, to count dead children and to talk about cost-effectiveness in the same sentence as a dying child. But if you think about it, working out the most cost-effective way of saving as many children’s lives as possible is the least heartless exercise of them all.

Just as I have urged you to look behind the statistics at the individual stories, I also urge you to look behind the individual stories at the statistics. The world cannot be understood without numbers. And it cannot be understood with numbers alone.

You tend to get things out of proportion. I do not mean to sound rude. Getting things out of proportion, or misjudging the size of things, is something that we humans do naturally. It is instinctive to look at a lonely number and misjudge its importance. It is also instinctive—like in the hospital in Nacala—to misjudge the importance of a single instance or an identifiable victim. These two tendencies are the two key aspects of the size instinct.

The media is this instinct’s friend. It is pretty much a journalist’s professional duty to make any given event, fact, or number sound more important than it is. And journalists know that it feels almost inhuman to look away from an individual in pain.

The two aspects of the size instinct, together with the negativity instinct, make us systematically underestimate the progress that has been made in the world. In the test questions about global proportions, people consistently say about 20 percent of people are having their basic needs met. The correct answer in most cases is close to 80 percent or even 90 percent. Proportion of children vaccinated: 88 percent. Proportion of people with electricity: 85 percent. Proportion of girls in primary school: 90 percent. The use of numbers that sound enormous, together with constant images of individual suffering presented by the charities and the media, distort people’s view of the world and they systematically underestimate all these proportions and all this progress.

At the same time, we systematically overestimate other proportions. The proportion of immigrants in our countries. The proportion of people opposed to homesexuality. In each of these cases, at least in the United States and Europe, our interpretations are more dramatic than the reality.

The size instinct directs our limited attention and resources toward those individual instances or identifiable victims, those concrete things right in front of our eyes. Today there are robust data sets for making the kinds of comparisons I made in Nacala on a global scale, and they show the same thing: It is not doctors and hospital beds that save children’s lives in countries on Levels 1 and 2. Beds and doctors are easy to count and politicians love to inaugurate buildings. But almost all the increased child survival is achieved through preventive measures outside hospitals by local nurses, midwives, and well-educated parents. Especially mothers: the data shows that half the increase in child survival in the world happens because the mothers can read and write. More children now survive because they don’t get ill in the first place. Trained midwives assist their mothers during pregnancy and delivery. Nurses immunize them. They have enough food, their parents keep them warm and clean, people around them wash their hands, and their mothers can read the instructions on that jar of pills. So if you are investing money to improve health on Level 1 or 2, you should put it into primary schools, nurse education, and vaccinations. Big impressive-looking hospitals can wait.