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Logo of bmjThis ArticleThe BMJ
BMJ. 2008 January 12; 336(7635): 100.
PMCID: PMC2190273
Outside the Box

Development lesson

Trisha Greenhalgh, professor of primary health care, University College London

I was waiting on a dusty street corner in one of Africa’s poorest countries, with six teenagers. To pass the time, I invited them to give me 10 differences between “third world” and ‘‘first world’’ countries.

“Easy,” said one. “We’re doing this in Geography. GDP.”

“Okay, so people don’t earn much. What’s the impact of that?”

They surveyed the rows of stinking slums. “People can’t afford nice houses. No kitchens or bathrooms. And the roofs sometimes fall off.”

“Why do you think they don’t earn enough money to buy nice houses?”

“I think they might not be able to read. And there probably aren’t enough jobs to go round.”

“Why not?”

Silence while they contemplated where jobs come from.

“Well, they can’t work on a farm because there’re no farms. Nothing grows here.”

This was true. The country was built on rock.

“And no factories either. All the goods are imported.”

“You could build a business, like those call centres they have in India. But I guess they don’t know how.”

We were observing a man arc welding pipes in the middle of the pavement, surrounded by hordes of barefoot children. Car horns drowned the imam’s chant from the nearby mosque.

“They don’t seem to care about safety. Everyone drives really crazy.” We recalled the limbless beggars and the little boy with the missing eye.

“What about health?” I asked.

“I think they would get diseases living so close together and having to poo in the drain.”

“If you didn’t have a job you’d get depressed.”

“They have way more children. I guess because some of them die. The mothers must get really tired.”

“People think it’s cool to smoke”—pointing to an enormous billboard advertising Camel cigarettes.

A man limped by on a disfigured club foot. I explained that this was probably congenital.

“So if you’re born with some problem they can’t fix it like they could in England.”

Our lift was finally pulling up. One final question: “Right, you clever kids, how would you solve all these problems?”

Eventually one of them ventured a solution. “I think,” she said tentatively, “I would start by building a school.”

Articles from The BMJ are provided here courtesy of BMJ Publishing Group