The life-saving power of… paperwork?

Nowhere are the differences clearer than in healthcare. Technically, it’s long been available to everyone thanks to the universal health law that was passed when Andrés and Marleny were kids. In practice, however, the barriers to access are often insurmountable: a lack of reliable transport; clinics, which are understaffed and often difficult to reach; Doctors and nurses, who may be hostile to the Black and Indigenous communities they serve; and a bureaucratic jumble of transfers and permits that makes all these things worse. Eliad spent almost a month in the intensive care unit in Puerto Asís, but it wasn’t 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 these towns to reach. The family had to travel from San Luis to Villagarzón, spend the night there and take a six-hour bus ride to Pasto the next morning. The distance between Villagarzón and Pasto is less than 100 miles, but a stretch of road connecting the two towns is widely considered the worst in all of Colombia. Known as “the trampoline of death” and rumored to be full of ghosts, it meanders along hairpin-thin ridges that give way to 100-foot drops on one side and sheer, mud-prone cliffs on the other. Marleny was already unwell, having injured her hip in a recent fall, but Eliad wasn’t a picky baby; he slept peacefully in Andrés’ arms for most of the journey. The doctor in Pasto was nice. She saw Eliad immediately and carefully studied the notes Marleny brought from the other hospitals. But she was also firm. The baby had several serious birth defects, including a heart murmur that required surgery for him, and pulmonary stenosis, which meant a valve connecting his heart to his lungs narrowed as he grew. He would still need to grow a bit before any surgeries could be performed, and in the meantime Marleny and Andrés would have to watch out for doctor appointments and follow-up care. They would also have to keep their hopes in check: some children, like her son, recovered through surgery and survived to adulthood, but many did not.

At home, Eliad gave no sign that he suspected these great opportunities. He willingly suckled, smiled and cooed, charming his mother. Marleny took countless photos and videos of him on her phone and silenced Andrés when he reminded her to save battery power for emergencies. Her son was lively and spirited, she thought. And he seemed to be getting stronger. While they waited for him to grow into his first surgery, she couldn’t help but nurture a little bloom of hope.

for decades, The burden of registering births and deaths—counting the uncounted—was primarily on the health authorities. When MacFeely joined the World Health Organization in 2021, he was surprised to find how unsolvable the problem seemed. “I wrote a blog post about it, and people came up and said, ‘Oh, we made the same argument 30 years ago,'” he told me recently. “I wonder how the hell is that still a problem these days?” But in the years since, he’s realized that the challenge of getting accurate birth and death counts is far greater than the health ministries tasked with dealing with them to deal with. It’s not just that the health authorities don’t control the registers or the wallets. The point is that the registers affect and are involved in every aspect of the state: public health, local governance, basic human rights. MacFeely now views the problem as a tragedy of the commons. Birth and death numbers are like the environment or the ocean, he says: because nobody really owns them, nobody takes responsibility for fixing them.

Nevertheless, progress is being made. In Rwanda, officials have changed laws to make registration easier and have greatly increased the number of registrars across the country. In Bangladesh, the national government has established a cabinet-level office dedicated to building a modern civil registry and personal statistics program. And in Colombia, a new central computer system will soon make it much easier to turn key event data into statistics that can be used to guide health policy. In all these countries and elsewhere, oral autopsy initiatives and mobile technologies are being used. “It’s no longer a pipe dream to say we can count all births and deaths everywhere,” says Setel, Vital Strategies’ anthropologist. “We have the technology for it. It doesn’t even have to be super expensive.”