Nowhere are the disparities more apparent than in health care. Technically, it has long been available to all, thanks to the universal health care law passed when Andrés and Marleny were children. But in practice, the barriers to access are often insurmountable: a lack of reliable transportation; clinics that are understaffed and often difficult to reach; doctors and nurses who can be hostile to the Black and Indigenous communities they serve; and a bureaucratic thicket of referrals and authorizations that exacerbates all those things. Eliad spent nearly a month in intensive care in Puerto Asís, but it was not until his follow-up appointments — at three different hospitals in three different cities — that the nature and extent of his condition became clear.
Pasto was the most difficult of those cities to get to. The family had to travel from San Luis to Villagarzón, stay overnight and then take a six-hour bus ride to Pasto early the next morning. The distance between Villagarzón and Pasto is less than 100 miles, but a stretch of road linking the two cities is widely regarded as the worst in all of Colombia. Known as “the trampoline of death” and said to be teeming with ghosts, it snakes along hairpin-thin mountain ridges that give way to 100-foot drops on one side and steep mudslide-prone cliffs on the other. Marleny was already uncomfortable, having recently injured her hip in a fall, but Eliad was not a fussy baby; he slept peacefully in Andrés’s arms for most of the ride. The doctor in Pasto was kind. She saw Eliad right away and made careful study of the notes Marleny brought from the other hospitals. But she was also firm. The baby had several serious birth defects, including a heart murmur for which he would need surgery and pulmonary stenosis, which meant that a valve connecting his heart to his lungs was narrowing as he grew. He would have to grow a little more before any operations could be performed, and in the meantime Marleny and Andrés would have to be vigilant about doctors’ appointments and follow-up care. They would also have to keep their hopes in check: Some children like their son recovered with surgery and survived to adulthood, but many did not.
Back home, Eliad gave no sign that he sensed these long odds. He suckled readily, smiled and cooed, charmed his mother. Marleny took scores of pictures and videos of him on her cellphone, hushing Andrés whenever he reminded her to conserve battery power for emergencies. Their son was feisty and spirited, she thought. And he seemed to be getting stronger. As they waited for him to grow into his first operation, she could not help but nurture a small blossom of hope.
For decades, the burden of fixing birth and death registries — of counting the uncounted — has rested mostly on health officials. When MacFeely joined the World Health Organization in 2021, he was surprised to discover how intractable the problem seemed. “I wrote a blog post about it, and people were reaching out saying, ‘Oh, we made the same arguments 30 years ago,’” he told me recently. “I’m like, how the hell is this still a problem in this day and age?” But in the years since, he has come to see the challenge of accurate birth and death counts as much bigger than the health ministries charged with addressing them. It’s not just that health officials don’t control the registries or the purse strings. It’s that the registries implicate, and are implicated in, every aspect of the state: public health, local governance, basic human rights. MacFeely has come to think of the issue as a tragedy of the commons. Birth and death counts are like the environment or the ocean, he says: Because nobody quite owns them, no one takes responsibility for fixing them.
Progress is nonetheless being made. In Rwanda, officials have amended laws to make registration easier and have vastly expanded the number of registration offices throughout the country. In Bangladesh, the national government has created a cabinet-level office devoted to building a modern civil registration and vital statistics program. And in Colombia, a new central computerized system will soon make it far easier to churn vital event data into the kind of statistics that can be used to guide health policy. Verbal-autopsy initiatives are taking root and mobile technology is being employed in all those countries and elsewhere. “It’s not a pipe dream anymore to say that we can count all births and deaths everywhere,” says Setel, the Vital Strategies anthropologist. “We have the technology to do that. It doesn’t even necessarily need to be superexpensive.”