A birth. A death. And a tragedy for lack of paperwork.

Nowhere are the differences as clear as in healthcare. Technically, it has long been available to everyone, thanks to the universal health care law that was passed when Andrés and Marleny were kids. But in practice, the barriers to entry are often insurmountable: a lack of reliable transport; 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 of those things. Eliad spent nearly a month in intensive care 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 apparent.

Pasto was the most difficult of those towns to reach. The family had to travel from San Luis to Villagarzón, stay overnight, and 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 road connecting the two towns is widely considered the worst in all of Colombia. Known as “the trampoline of death” and reportedly teeming with ghosts, it winds past hairpin-thin ridges that give way to 100-foot drops on one side and sheer cliffs prone to mudslides 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 arms for most of the ride. The doctor in Pasto was nice. She saw Eliad right away and carefully studied the notes Marleny had brought from the other hospitals. But she was also steadfast. The baby had several serious birth defects, including a heart murmur that would require surgery and pulmonary stenosis, which meant a valve connecting his heart to his lungs narrowed as he grew. He would have to grow some more before surgery could be performed, and in the meantime, Marleny and Andrés would have to be vigilant about doctor appointments and follow-up care. They should also keep their hopes in check: Some children, like their son, recovered with surgery and survived to adulthood, but many did not.

At home, Eliad gave no sign of sensing these great opportunities. He liked to suckle, smile and coo, enchanted his mother. Marleny took dozens of photos and videos of him on her cell phone and silenced Andrés when he reminded her to save the battery for emergencies. Their son was feisty and lively, she thought. And he seemed to be getting stronger. As they waited for him to grow into his first surgery, she couldn’t help but harbor a little hope.

For decades, the burden of compiling birth and death records — of counting the countless — rests largely on health officials. When MacFeely joined the World Health Organization in 2021, he was surprised to discover how persistent the problem seemed. “I wrote one blog post about it, and people would contact me and say, ‘Oh, we were having the same arguments 30 years ago,'” he told me recently. “I’m like, how on earth is this still an issue in this day and age?” But in the years since, he’s come to see that the challenge of accurate birth and death counts is far greater than the ministries of health charged with tackling it. It’s not just that health officials have no control over the records or the wallet. It’s that the registries are involved in every aspect of the state: public health, local government, basic human rights. MacFeely has come to view the issue as a tragedy of the commons. Birth and death rates are like the environment or the ocean, he says: Because no one really owns them, no one takes responsibility for fixing them.

Nevertheless, progress is being made. In Rwanda, officials have changed the laws to make registration easier and have greatly expanded the number of registration offices across the country. In Bangladesh, the national government has established a cabinet-level office dedicated to establishing a modern civil registry and vital statistics program. And in Colombia, a new central computerized system will soon make it much easier to turn vital event data into the kind of metrics that can be used to guide health policy. In all of those countries and elsewhere, verbal autopsy initiatives are taking root and mobile technology is being used. “It’s no longer utopia to say we can count all births and deaths everywhere,” said Setel, Vital Strategies’ anthropologist. “We have the technology to do that. It doesn’t even have to be super expensive.”