This one crossed the finish line a few weeks back. I’m pretty happy with the final product, but I do lament the loss of this bit which felt both colorful and important to me. Most of it made it into the final draft in different form, but I liked the structure and flow here and I don’t think I was able to capture it as well in rewrite.
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In Seeing Like A State, his seminal history of social engineering schemes gone awry, Yale political scientist James C. Scott details the power of statistics to not only describe reality, but to shape it. Before we can manipulate or control the world around us, Scott explains, we have to map it. Before we can map it, we must distill it down to a handful of what he calls synoptic details. It’s this distilling that warps reality. “There are virtually no other facts for the state than those that are contained in documents,” he writes. “An error in such a document can have far more power, and for far longer, than can an unreported truth.” Scott’s examples deal mostly with urban planning — the making of cadastral maps, the design of cities, the metric system — but his thesis applies equally well to the global quest against disease and death. If there is a single essential prerequisite to that quest, it is an accurate head count. Some initiatives — vaccination, clean water, nutritious food — are no-brainers. But without an adequate sense of how many people are being born and how many are dying (and where and of what and at what age) even those triumphs can only ever be partial.
Victor Hugo glimpsed this phenomenon first hand in the late 1980s, when he was a newly-minted doctor working in Colombia’s Orinoco region. The Orinoco is an almost unfathomably vast swath of wilderness, and Victor and his colleagues would trek for months at a time through rainforest and grassland, delivering supplies to the small and widely dispersed indigenous communities that dot the region, and providing what medical care they could. The list of ailments was long: malnourishment, respiratory and parasitic infections, mosquito-borne and diarrheal diseases, preventable contagions like measles, mumps and rubella. The official response to these crises was maddeningly off-kilter, Victor says. Donor nations would send incubators to communities that had no electricity. The national government would provide loads of medications of varying practical use, but do little to address the clean water crisis that was making people sick to begin with. For their part, Victor and his colleagues would spray DDT indiscriminately, and then watch with bewilderment as mosquito-borne diseases came roaring back in some places, but not others.
The problem, he quickly realized, came down to a lack of data. The Colombian government had little presence and little apparent interest in the regions where he was working. Because they didn’t care, they didn’t count. Because they didn’t count, they couldn’t see. And because they couldn’t see, they not only couldn’t fix, they couldn’t necessarily grasp what there was to fix in the first place. “You can’t understand what’s happening, or make a plan to fix it if you don’t know how many people you have to begin with,” says Victor, who has spent nearly three decades at Colombia’s Ministry of Health and Social Protection. “You also can’t really tell if what you’re doing is working or not if you don’t know how many cases you have, of which diseases in which places.”
In the Orinoco, such data was paltry. “Community leaders would report births and deaths and disease outbreaks to the radio technicians who manned the war sentinels,” he says. “And the technicians would write that information down on napkins or whatever scraps of paper they had.” Sometimes health workers like him would collect scraps, and sometimes they wouldn’t. Victor began training community members to collect that data more systematically, so that it could be organized into reports and used to guide their efforts. He designed forms and created databases. Almost immediately, he says, patterns emerged. For example, the communities where malaria returned after DDT was sprayed had a much higher proportion of people who worked in the mines where nobody was spraying at all.
At the time, there was still no real civil registration system in Colombia. Births, deaths and marriages were logged first and foremost by the Catholic church. In fact, parents could not even obtain birth certificates for their children without baptizing them. But that began to change in 1991, when a new constitution divorced the church from such matters of state. In 1993, a law guaranteeing health care to all citizens created new incentives for parents to register their children with the national government. Victor joined the health ministry in 1995 and began working to merge a roster of disparate entities into a new agency that could collect that data and use it to produce statistics. By 1998, that system had been fully established, he says. Within a decade it was almost completely digitized. But if those advances improved the government’s ability to count and analyze its population, they also created a yawning disparity between wealthy urban centers like Bogota and Medellin, and impoverished rural regions that claim most of the nation’s physical space. “Nationally, we have about 85 to 90 percent coverage now,” Victor told me. “But that last 15 percent makes up the poorest, most disenfranchised segment of the population. They live in regions where armed groups still have more control than the national government. You’re talking about five or six million people. And because they aren’t registered, it’s as if they don’t exist.”