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Implications of demographic change Ian Lee Doucet BA DipM
a
a
Medical Educational Trust , 601 Holloway Road, London, N19 4DJ Published online: 22 Oct 2007.
To cite this article: Ian Lee Doucet BA DipM (1992) Implications of demographic change, Medicine and War, 8:4, 294-301, DOI: 10.1080/07488009208409063 To link to this article: http://dx.doi.org/10.1080/07488009208409063
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access
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CONFERENCE REPORT
Implications of Demographic Change IAN LEE DOUCET BADipM
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Medical Educational Trust, 601 Holloway Road, London N 19 4D]
The one-day symposium, 'Implications of Demographic Change', was organized by the Royal Society of Tropical Medicine and Hygiene and held at the Royal College of Physicians on 11 May 1992. Through the differences in approach ran a question which appeared again in June at the UNCED 'Earth Summit' in Rio: is it over-population (in developing countries) or over-consumption (by the industrialized) which threatens the global ecosystem? Bodies such as the Overseas Development Administration (ODA) and UNICEF were well represented and, by the nature of their work, kept the conference's focus on over-population and the Third World. (Which leads to the thought, what equivalent organizations examine and try to remedy global over-consumption by industrialized countries?) There was little mention of the third limit to growth: pollution, although there is strong evidence that we will reach the limits of the earth's capacity to absorb our wastes long before we deplete its resources. Two speakers focused on the wider ecological context within which demographic change, population control and other aid interventions occur, and their complex effects on the ability of an ecosystem to sustain population numbers and lifestyles. This wider focus seemed at odds with the concentration of most speakers, notably the aid agencies, on 'fertility' of women in poor countries, defined as the average number of children per woman. All eight speakers and both chairpeople were male; a final panel discussion included women. In the report which follows additional information is given in parentheses. Numbers World population has doubled since 1950 to 5.4 billion. By early next century it will have doubled again or even trebled, said Dr David Nabarro, Chief Health and Population Adviser to the ODA, opening the conference with a brief factual survey. By 2050 global population will range from 8.5 billion (a highly optimistic prediction) to 12.5 billion. Of this growth, 95 per cent is in Third World countries. [The UN Fund for Population Activities (UNFPA) has produced low, MEDICINE AND WAR, VOL. 8,294-301 (1992)
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medium and high projections of population growth.1 An average projection is that the world population will almost double to reach 10 billion in the next 58 years, by 2050, and continue growing to 11.6 billion for another century. The maximum population the planet can sustain has been estimated as 9.5 billion. Even so, this medium projection assumes a dramatic drop in fertility from 3.9 children per woman to 2.1. The low and high projections give a range of 8.5 to 12.5 billion by 2050. Adding an historical perspective suggests what these predictions may mean in practice. The current total of 5.4 billion represents a doubling of the 1950 total of 2.5 billion. As population has risen, global food production has fallen - grain production fell 5 per cent in 1987 and again in 1988 from the record harvests of 1986. Canada, the Soviet Union and China suffered severe drought and crop failure, while the US grain harvest fell most, being 27 per cent down in 1988 from the previous year. Over 100 countries rely on food imports from the United States. In Africa, where population is increasing most rapidly and where 34 per cent of the growth is predicted, harvests have been falling for several years, with major shortages reported in 1992.2] Fertility
Dr Nabarro also outlined some of the conflicting aspects of this unprecedented growth in global population. For example, population control measures have made some progress. Fertility rates have fallen significantly in some developing countries, from an average of six children per woman to less than four. There is massive demand for contraceptive services, not by governments but by people in the Third World who desperately want to control their own fertility. Population control is about giving people this choice; the right of people to choose in relation to their fertility is paramount and concern about global over-population is secondary to this. However, this subject raises a mixture of moral and practical problems: who should pay for programmes of population control? Has the State a right to dictate familysize? Which population policies best meet the needs of developing countries? What is the role on non-governmental organizations? How will the spread of HIV affect population-growth projections and policies based on these projections? And how does the need to increase child survival fit into policies of population control? Drjohn Blacker of the Centre for Population Studies at the London School of Hygiene and Tropical Medicine presented a more detailed picture of population trends. In China fertility fell from 1970 to 1982, and most of this fall preceded the government's one-child policy introduced in 1979; but there were very large fluctuations, from highs of seven (children per woman) in 1965 and six in 1975, to lows of 3.3 in 1960 and 1980. In Latin America there was a downward trend; for example, fertility in Brazil fell from six to three from 1950 to 1990. In other countries the picture is less promising. While many Latin American countries now have average fertility below four, others
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remain higher, such as Bolivia with more than six children per woman. In India fertility fell from 5.7 to 4.7 from 1950 to 1970, but has remained stable since then. Bangladesh has fertility over seven and Pakistan over six. In much of Africa fertility rose in the 1960s and 1970s, though part of this may result from differences in data-collection; in many African countries these increases were due to more births of sixth, seventh and eighth children. The overall question is whether population will be limited by reductions in birth rate or increases in death rate, said Dr Blacker. Despite lack of statistical proof, it is likely that childhood mortality in the Third World has increased in recent years. Most causes of childhood mortality are preventable. Improvements in child mortality can gain a momentum which leads to improvement in living conditions and reductions in fertility, as in Ghana. On the other hand, population growth also has a built-in momentum, producing more potential mothers in each generation. One of the key factors reducing child mortality is improved maternal education. Questioners pointed out how complex are the effects of development on population. Traditions of length of breast-feeding and post-partum abstinence strongly influence the number of children a woman bears, in the absence of artificial contraception. Modernization, which disrupts these traditions, may lead to increases in fertility. Similarly, rising age of marriage may lower fertility, or increase it since too early childbearing tends to reduce malnourished mothers' subsequent fertility and their children's chances of survival. High fertility is linked to many factors, including low status of women. High human fertility can be both a cause and a consequence of poverty. Other questioners argued that family planning is not the same as population control, and population control is only one aspect of demography. Why does contraception concentrate exclusively on women? Most effective in reducing fertility is a combination of birth spacing and family planning; these are justified in their own right in terms of improving mother and child health regardless of effects on population. [A World Health Organisation report3 this year states that fertility rates have fallen dramatically in the developing world, from 6.1 children per woman in 1965 to 3.9 currently. About 380 million people in the developing world use artificial contraception, and a further 300 million want to but have no access to family planning services. Comparative fertility rates are given more fully in the UN Development Programme's Human Development Report 1992/] Numbers versus Lifestyle Is the global environmental threat from excessive numbers of poor in the South or from excessive consumption by the North? This fundamental question was raised several times at the conference but not clarified, with speakers tending to fall into one or the other camp. Dr Ulrich Loening of the
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Centre for Human Ecology at the University of Edinburgh described the complex interplay between population, environment and economics. The present world population puts an unprecedented burden on the earth's carrying capacity, and may soon exceed it. Population growth is just one aspect of demographic change, and many other factors influence population and its environmental impact: consumption, quality of life, patterns of trade and resource use, and other aspects of global politics should be taken into account. It is relevant to population growth and its environmental consequences that 500 companies control 70 per cent of the world's trade. The current GATT 'free' trade moves will work against efforts to curb population growth and lead to greater inequity and nonsustainability. The Brundtland Commission of 1987 stated that sustainability and equity are preconditions for economic development, and that human activity must be fitted into nature's patterns and capacities. But human activity has consistently overridden and contradicted the ecological context on which life depends. Dr Loening contrasted the two: nature works in cycles and recycles all materials, without waste or excess, combines competition with cooperation, and increases biological diversity and global stability, through multiple feedback controls which are mostly negative. In contrast, humans work linearly, consume resources without renewal, with waste and deliberate excesses, by overriding natural systems, decreasing diversity and causing global changes through paucity of feedback controls, which are mostly positive. Dr Loening explained the difference between negative and positive feedback: nature's negative feedback means that having done something once you can do it less next time, whereas the positive feedback of human activity assumes that having done something once you can then do it more next time. Human feedback control operates through individual consciousness or conscience and through the political/social system, so may be amenable to change through information and debate. It is populations' consumption which affects the ecosystem, so that we need to look beyond population numbers towards reducing consumption per capita in the rich countries. But, Dr Loening concluded, it is difficult to correct the consequences of inequity from a position of inequity! Professor Robert Cassen of the International Development Centre at the University of Oxford, speaking on the economic implications of demographic change, insisted that it was important to separate environmental effects due to population growth from other causes. If depreciation of natural resources is ignored, as it has been in conventional economics, then population growth is a beneficial factor encouraging economic growth. Unsurprisingly, the opposite is the case if environmental depletion and pollution are taken into account, and if a longer term view is taken. Again, the interplay of forces is complex: much of the environmental destruction in the Third World has been due to factors other than population growth; in some parts of Africa soil productivity has improved with population growth. But urban population growth is always detrimental to the environment.
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[Over-population and over-consumption are not competing causes of environmental degradation, as discussion at the conference often implied. And a third factor, over-pollution, should not be ignored. The UNFPA report1 states that 'The fastest-ever growth in human consumption of resources is compounded by economic and political systems unaware of any limits to growth.' It calls for a 'direct attack' on the roots of poverty, including unfair trade systems, international debt, the low status of women, and inequitable distribution of resources, as the only way of slowing population growth. Others5'6 argue that human interaction with the environment is a system with many elements which interact, so we cannot pick out one element as an 'ultimate cause'. Population, consumption and pollution interact and contribute differently to the global crisis. The limits of pollution will be reached before resources are depleted, and different consumption patterns greatly influence pollution: one person in the developing world produces 149 times his/her bodyweight in municipal waste on average during a lifetime, while the average European produces 971 times and the average North American produces almost 4,000 times his/her bodyweight; adding other wastes, such as mining, building and sewage, would quadruple the European and North American totals.5 The different factors operate over different timescales: Population growth increases many types of damage to the environment. Slowing that growth reduces the damage. But it may be 20 years before there is any noticeable effect. In the shorter term, other measures will have greater impact: reducing consumption, shifting to sustainable technologies, attacking poverty and inequality, introducing land reform. But in the medium to long term, reducing population growth can have very significant impact. To achieve this, governments, development agencies and donors of aid must focus their attention on enhancing the rights, education and health of women and children.6] Demographic Traps? Difficult philosophical and practical questions were raised by Dr Maurice King, of the Department of Community Medicine at the University of Leeds. These seemed to be misunderstood or caricatured rather than addressed, notably by the major agencies represented at the conference. Dr King focused on the planet's 'carrying capacity' (ecological systems can sustain just so much usage before deteriorating) and on 'entrapment' (populations get trapped in ecosystems whose carrying capacity has been exceeded, with only starvation and disease or migration or external aid as escapes). The demographic trap occurs when a population finds itself in an unsustainable state with high birth and death rates, ever-increasing pressure on its resources and a deteriorating environment. If no other sustaining measures are taken, then introducing such measures as oral rehydration to reduce child mortality will
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be desustaining. Thus the short-term effects of aid, development and public health programmes may sometimes worsen the prospects of long-term survival. It also suggests conflict between individual and collective survival, and between survival of today's populations and of future populations. Dr Richard Jolly, Deputy Executive Director of UNICEF, argued that this was fallacious: if the 14 million children dying each year preventably was halved this would add only an insignificant 7 million to the global population. Lowering child mortality actually reduces future fertility. Describing UNICEF policy, he said that there is much evidence that reducing infant and child mortality in combination with promoting family planning will be accompanied by even greater reductions in fertility, thus reducing future population growth. [King's views7 have been much attacked elsewhere, on the assumption that he is arguing in favour of high mortality in order to slow population growth. But instead he may be understood to be arguing for current mortalityreduction measures to be combined with other environment-sustaining measures, and for all intervention to be measured in terms of the environment's carrying capacity. It has been counter-argued8 that if Nigeria let its child mortality increase by 100 per cent, that would only delay its population doubling-time from 22 to 28 years hence. Population growth in countries such as Nigeria and Yemen is exceptionally high because they are passing through a demographic transition from high to lower death rates, whilst the birth rate remains high. What is needed is rapid reduction in the high fertility rate, which can be achieved by economic progress, improvements for women, family planning, and increased child survival. King seems not to disagree with this; his point remains that mortality-reduction measures in isolation may prolong that transition phase, which will further reduce the environment's capacity to sustain the population. In fact, King and his critics share more common ground than their responses to each other suggest.' Thus one critic writes that sometimes improvements in soil fertility and agricultural yield will have more beneficial effect on health than medical intervention.8] Disease
How has population growth been affected by improved healthcare in some developing countries, and how will the spread of HIV affect current trends? Professor Roy Anderson, of the Department of Biology at Imperial College London, spoke on disease transmission in relation to population growth. Better treatment of sexually transmitted diseases (STD) reduces the sterility associated with STD and so may increase the number of children born. The impact of such health measures on fertility and population growth needs more thorough investigation. There have been many epidemics which are major causes of mortality but have had little general impact on population trends. For example, mortality from smallpox or respiratory tract infections can be very high but have only localized effects with little impact on national
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or regional population levels. Even 30 per cent case mortality is not enough to check a population growth rate of between four and five per cent. In contrast, population growth will be checked by an infectious disease which affects reproduction, has a long infectious period, has near 100 per cent mortality and is vertically (parent to child) transmitted as well as horizontally. HIV and AIDS, he said, fit this description. It is not the high-risk groups which have most effect on population, but pregnant women. In some African countries there is a 20—30 per cent risk of HIV infection, even with no other risk factor than being pregnant, and incubation is six years, not 10 years. Three factors are commonly overlooked which result in underestimating the spread of HIV in Africa: there is much mixing of high- and low-risk groups; women have more sexual partners at younger ages than men (on average the age gap is 10 years); and transmission from man to woman is much higher than vice versa. HIV can have a major demographic effect if seroprevalence reaches about 30%. In some African countries, for example Uganda, prevalence is very close to this after only a few decades of urban spread. In Asia, especially India, HIV is reaching African proportions; in Bombay and Pune nearly one-third of prostitutes were seropositive in 1991. Globally, by the year 2000 there will be 10 million AIDS orphans. The behavioural response to such high mortality is an unknown factor at present. [A report by the International Family Health organisation stated: 1 in 40 African adults is now infected with HIV. These 6 million women and men, and the three-quarters of a million infected children, are unevenly distributed over the continent. In East Africa the real burden of disease and death is only just beginning to be felt, but already AIDS cases make up 80% of the case-load in some adult hospital wards ... 1 in 8 adults in Abidjan now carry HIV1 or HIV2. The burden of associated diseases is overwhelming... Already there are 50,000 AIDS orphans in just one region (Kagera) of Tanzania, and agricultural production in the same area has fallen by 3-20%. Yet only a small fraction of those infected with HIV in any part of Africa have died. From the point of view of costs to the community and health services the epidemic is only just beginning.10 The UNFPA report1 on world population states that the spread of HIV and AIDS is unlikely to significantly alter projected population growth.] Money That Britain receives from developing countries four times more than it gives in aid was the most notable information given by Dr Peter Poore of Save the Children Fund, speaking on SCF policy. The conference took little note of the financial dimension, except to note that $9 billion (of which only $3.5 billion would come from the industrialized world) spent on family planning
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would achieve targets by 2000, and that this is very little, and highly costeffective. [Development aid is a very small proportion of industrialized countries' budgets. Many countries including Britain refuse to meet even the low norms for development aid. Britain's development aid was 8.1 per cent of its military budget in 1990; for the United States the ratio was even lower, at 3.8 per cent; France, Germany and Australia gave 16-17 per cent while Canada, Japan, Norway, Sweden, Denmark, Holland and several other countries gave development aid equal to 25-50 per cent of their military budgets. In Britain development aid as a proportion of gross national product fell from 0.56 per cent in 1960 to 0.27 per cent in 1990.4 Of these very small amounts of development aid, less than 1 per cent is spent on population policies and family planning; this is a reduction on the 2 per cent of aid money spent on population measures in the 1970s.11 Such considerations will influence which of the low, medium, or high UNFPA predictions cf population growth come about. No contributor to the conference expressed conviction that the low prediction, the only one not exceeding the earth's carrying capacity, would come about; meeting even the medium projection will require more governmental committment than exists at present.] References
1. State of the World Population 1992. New York: UNFPA, 1992. 2. Walker A. Health and the environment. Population: more than a numbers game. BMJ 1991; 303: 1194-7. 3. Reproductive Health, a Key to a Brighter Future. Geneva: WHO, 1992. 4. Human Development Report 1992. New York: United Nations Development Programme, 1992. 5. Harrison P. The Third Revolution. London: I B Tauris, 1992. 6. Harrison P. Too much life on Earth? New Scientist 19 May 1990: 28-9. 7. King M. Health is a sustainable state. Lancet 1990; 336: 664-7. 8. Lithell U-B, Rosling H, Hofvander Y. Children's deaths and population growth. Lancet 1992; 339: 377-8. 9. Editorial. Pressure on the eco-seams. Lancet 1992; 339: 1265-7 10. Potts M. AIDS in Africa. Lancet 1992; 339: 238. 11. Potts M. Europe: population concerns. Lancet 1992; 339: 605-6. (5 August 1992)
Medicine and War Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/fmcs19
Implications of demographic change Ian Lee Doucet BA DipM
a
a
Medical Educational Trust , 601 Holloway Road, London, N19 4DJ Published online: 22 Oct 2007.
To cite this article: Ian Lee Doucet BA DipM (1992) Implications of demographic change, Medicine and War, 8:4, 294-301, DOI: 10.1080/07488009208409063 To link to this article: http://dx.doi.org/10.1080/07488009208409063
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access
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and use can be found at http://www.tandfonline.com/page/terms-andconditions
CONFERENCE REPORT
Implications of Demographic Change IAN LEE DOUCET BADipM
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Medical Educational Trust, 601 Holloway Road, London N 19 4D]
The one-day symposium, 'Implications of Demographic Change', was organized by the Royal Society of Tropical Medicine and Hygiene and held at the Royal College of Physicians on 11 May 1992. Through the differences in approach ran a question which appeared again in June at the UNCED 'Earth Summit' in Rio: is it over-population (in developing countries) or over-consumption (by the industrialized) which threatens the global ecosystem? Bodies such as the Overseas Development Administration (ODA) and UNICEF were well represented and, by the nature of their work, kept the conference's focus on over-population and the Third World. (Which leads to the thought, what equivalent organizations examine and try to remedy global over-consumption by industrialized countries?) There was little mention of the third limit to growth: pollution, although there is strong evidence that we will reach the limits of the earth's capacity to absorb our wastes long before we deplete its resources. Two speakers focused on the wider ecological context within which demographic change, population control and other aid interventions occur, and their complex effects on the ability of an ecosystem to sustain population numbers and lifestyles. This wider focus seemed at odds with the concentration of most speakers, notably the aid agencies, on 'fertility' of women in poor countries, defined as the average number of children per woman. All eight speakers and both chairpeople were male; a final panel discussion included women. In the report which follows additional information is given in parentheses. Numbers World population has doubled since 1950 to 5.4 billion. By early next century it will have doubled again or even trebled, said Dr David Nabarro, Chief Health and Population Adviser to the ODA, opening the conference with a brief factual survey. By 2050 global population will range from 8.5 billion (a highly optimistic prediction) to 12.5 billion. Of this growth, 95 per cent is in Third World countries. [The UN Fund for Population Activities (UNFPA) has produced low, MEDICINE AND WAR, VOL. 8,294-301 (1992)
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medium and high projections of population growth.1 An average projection is that the world population will almost double to reach 10 billion in the next 58 years, by 2050, and continue growing to 11.6 billion for another century. The maximum population the planet can sustain has been estimated as 9.5 billion. Even so, this medium projection assumes a dramatic drop in fertility from 3.9 children per woman to 2.1. The low and high projections give a range of 8.5 to 12.5 billion by 2050. Adding an historical perspective suggests what these predictions may mean in practice. The current total of 5.4 billion represents a doubling of the 1950 total of 2.5 billion. As population has risen, global food production has fallen - grain production fell 5 per cent in 1987 and again in 1988 from the record harvests of 1986. Canada, the Soviet Union and China suffered severe drought and crop failure, while the US grain harvest fell most, being 27 per cent down in 1988 from the previous year. Over 100 countries rely on food imports from the United States. In Africa, where population is increasing most rapidly and where 34 per cent of the growth is predicted, harvests have been falling for several years, with major shortages reported in 1992.2] Fertility
Dr Nabarro also outlined some of the conflicting aspects of this unprecedented growth in global population. For example, population control measures have made some progress. Fertility rates have fallen significantly in some developing countries, from an average of six children per woman to less than four. There is massive demand for contraceptive services, not by governments but by people in the Third World who desperately want to control their own fertility. Population control is about giving people this choice; the right of people to choose in relation to their fertility is paramount and concern about global over-population is secondary to this. However, this subject raises a mixture of moral and practical problems: who should pay for programmes of population control? Has the State a right to dictate familysize? Which population policies best meet the needs of developing countries? What is the role on non-governmental organizations? How will the spread of HIV affect population-growth projections and policies based on these projections? And how does the need to increase child survival fit into policies of population control? Drjohn Blacker of the Centre for Population Studies at the London School of Hygiene and Tropical Medicine presented a more detailed picture of population trends. In China fertility fell from 1970 to 1982, and most of this fall preceded the government's one-child policy introduced in 1979; but there were very large fluctuations, from highs of seven (children per woman) in 1965 and six in 1975, to lows of 3.3 in 1960 and 1980. In Latin America there was a downward trend; for example, fertility in Brazil fell from six to three from 1950 to 1990. In other countries the picture is less promising. While many Latin American countries now have average fertility below four, others
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remain higher, such as Bolivia with more than six children per woman. In India fertility fell from 5.7 to 4.7 from 1950 to 1970, but has remained stable since then. Bangladesh has fertility over seven and Pakistan over six. In much of Africa fertility rose in the 1960s and 1970s, though part of this may result from differences in data-collection; in many African countries these increases were due to more births of sixth, seventh and eighth children. The overall question is whether population will be limited by reductions in birth rate or increases in death rate, said Dr Blacker. Despite lack of statistical proof, it is likely that childhood mortality in the Third World has increased in recent years. Most causes of childhood mortality are preventable. Improvements in child mortality can gain a momentum which leads to improvement in living conditions and reductions in fertility, as in Ghana. On the other hand, population growth also has a built-in momentum, producing more potential mothers in each generation. One of the key factors reducing child mortality is improved maternal education. Questioners pointed out how complex are the effects of development on population. Traditions of length of breast-feeding and post-partum abstinence strongly influence the number of children a woman bears, in the absence of artificial contraception. Modernization, which disrupts these traditions, may lead to increases in fertility. Similarly, rising age of marriage may lower fertility, or increase it since too early childbearing tends to reduce malnourished mothers' subsequent fertility and their children's chances of survival. High fertility is linked to many factors, including low status of women. High human fertility can be both a cause and a consequence of poverty. Other questioners argued that family planning is not the same as population control, and population control is only one aspect of demography. Why does contraception concentrate exclusively on women? Most effective in reducing fertility is a combination of birth spacing and family planning; these are justified in their own right in terms of improving mother and child health regardless of effects on population. [A World Health Organisation report3 this year states that fertility rates have fallen dramatically in the developing world, from 6.1 children per woman in 1965 to 3.9 currently. About 380 million people in the developing world use artificial contraception, and a further 300 million want to but have no access to family planning services. Comparative fertility rates are given more fully in the UN Development Programme's Human Development Report 1992/] Numbers versus Lifestyle Is the global environmental threat from excessive numbers of poor in the South or from excessive consumption by the North? This fundamental question was raised several times at the conference but not clarified, with speakers tending to fall into one or the other camp. Dr Ulrich Loening of the
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Centre for Human Ecology at the University of Edinburgh described the complex interplay between population, environment and economics. The present world population puts an unprecedented burden on the earth's carrying capacity, and may soon exceed it. Population growth is just one aspect of demographic change, and many other factors influence population and its environmental impact: consumption, quality of life, patterns of trade and resource use, and other aspects of global politics should be taken into account. It is relevant to population growth and its environmental consequences that 500 companies control 70 per cent of the world's trade. The current GATT 'free' trade moves will work against efforts to curb population growth and lead to greater inequity and nonsustainability. The Brundtland Commission of 1987 stated that sustainability and equity are preconditions for economic development, and that human activity must be fitted into nature's patterns and capacities. But human activity has consistently overridden and contradicted the ecological context on which life depends. Dr Loening contrasted the two: nature works in cycles and recycles all materials, without waste or excess, combines competition with cooperation, and increases biological diversity and global stability, through multiple feedback controls which are mostly negative. In contrast, humans work linearly, consume resources without renewal, with waste and deliberate excesses, by overriding natural systems, decreasing diversity and causing global changes through paucity of feedback controls, which are mostly positive. Dr Loening explained the difference between negative and positive feedback: nature's negative feedback means that having done something once you can do it less next time, whereas the positive feedback of human activity assumes that having done something once you can then do it more next time. Human feedback control operates through individual consciousness or conscience and through the political/social system, so may be amenable to change through information and debate. It is populations' consumption which affects the ecosystem, so that we need to look beyond population numbers towards reducing consumption per capita in the rich countries. But, Dr Loening concluded, it is difficult to correct the consequences of inequity from a position of inequity! Professor Robert Cassen of the International Development Centre at the University of Oxford, speaking on the economic implications of demographic change, insisted that it was important to separate environmental effects due to population growth from other causes. If depreciation of natural resources is ignored, as it has been in conventional economics, then population growth is a beneficial factor encouraging economic growth. Unsurprisingly, the opposite is the case if environmental depletion and pollution are taken into account, and if a longer term view is taken. Again, the interplay of forces is complex: much of the environmental destruction in the Third World has been due to factors other than population growth; in some parts of Africa soil productivity has improved with population growth. But urban population growth is always detrimental to the environment.
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[Over-population and over-consumption are not competing causes of environmental degradation, as discussion at the conference often implied. And a third factor, over-pollution, should not be ignored. The UNFPA report1 states that 'The fastest-ever growth in human consumption of resources is compounded by economic and political systems unaware of any limits to growth.' It calls for a 'direct attack' on the roots of poverty, including unfair trade systems, international debt, the low status of women, and inequitable distribution of resources, as the only way of slowing population growth. Others5'6 argue that human interaction with the environment is a system with many elements which interact, so we cannot pick out one element as an 'ultimate cause'. Population, consumption and pollution interact and contribute differently to the global crisis. The limits of pollution will be reached before resources are depleted, and different consumption patterns greatly influence pollution: one person in the developing world produces 149 times his/her bodyweight in municipal waste on average during a lifetime, while the average European produces 971 times and the average North American produces almost 4,000 times his/her bodyweight; adding other wastes, such as mining, building and sewage, would quadruple the European and North American totals.5 The different factors operate over different timescales: Population growth increases many types of damage to the environment. Slowing that growth reduces the damage. But it may be 20 years before there is any noticeable effect. In the shorter term, other measures will have greater impact: reducing consumption, shifting to sustainable technologies, attacking poverty and inequality, introducing land reform. But in the medium to long term, reducing population growth can have very significant impact. To achieve this, governments, development agencies and donors of aid must focus their attention on enhancing the rights, education and health of women and children.6] Demographic Traps? Difficult philosophical and practical questions were raised by Dr Maurice King, of the Department of Community Medicine at the University of Leeds. These seemed to be misunderstood or caricatured rather than addressed, notably by the major agencies represented at the conference. Dr King focused on the planet's 'carrying capacity' (ecological systems can sustain just so much usage before deteriorating) and on 'entrapment' (populations get trapped in ecosystems whose carrying capacity has been exceeded, with only starvation and disease or migration or external aid as escapes). The demographic trap occurs when a population finds itself in an unsustainable state with high birth and death rates, ever-increasing pressure on its resources and a deteriorating environment. If no other sustaining measures are taken, then introducing such measures as oral rehydration to reduce child mortality will
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be desustaining. Thus the short-term effects of aid, development and public health programmes may sometimes worsen the prospects of long-term survival. It also suggests conflict between individual and collective survival, and between survival of today's populations and of future populations. Dr Richard Jolly, Deputy Executive Director of UNICEF, argued that this was fallacious: if the 14 million children dying each year preventably was halved this would add only an insignificant 7 million to the global population. Lowering child mortality actually reduces future fertility. Describing UNICEF policy, he said that there is much evidence that reducing infant and child mortality in combination with promoting family planning will be accompanied by even greater reductions in fertility, thus reducing future population growth. [King's views7 have been much attacked elsewhere, on the assumption that he is arguing in favour of high mortality in order to slow population growth. But instead he may be understood to be arguing for current mortalityreduction measures to be combined with other environment-sustaining measures, and for all intervention to be measured in terms of the environment's carrying capacity. It has been counter-argued8 that if Nigeria let its child mortality increase by 100 per cent, that would only delay its population doubling-time from 22 to 28 years hence. Population growth in countries such as Nigeria and Yemen is exceptionally high because they are passing through a demographic transition from high to lower death rates, whilst the birth rate remains high. What is needed is rapid reduction in the high fertility rate, which can be achieved by economic progress, improvements for women, family planning, and increased child survival. King seems not to disagree with this; his point remains that mortality-reduction measures in isolation may prolong that transition phase, which will further reduce the environment's capacity to sustain the population. In fact, King and his critics share more common ground than their responses to each other suggest.' Thus one critic writes that sometimes improvements in soil fertility and agricultural yield will have more beneficial effect on health than medical intervention.8] Disease
How has population growth been affected by improved healthcare in some developing countries, and how will the spread of HIV affect current trends? Professor Roy Anderson, of the Department of Biology at Imperial College London, spoke on disease transmission in relation to population growth. Better treatment of sexually transmitted diseases (STD) reduces the sterility associated with STD and so may increase the number of children born. The impact of such health measures on fertility and population growth needs more thorough investigation. There have been many epidemics which are major causes of mortality but have had little general impact on population trends. For example, mortality from smallpox or respiratory tract infections can be very high but have only localized effects with little impact on national
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or regional population levels. Even 30 per cent case mortality is not enough to check a population growth rate of between four and five per cent. In contrast, population growth will be checked by an infectious disease which affects reproduction, has a long infectious period, has near 100 per cent mortality and is vertically (parent to child) transmitted as well as horizontally. HIV and AIDS, he said, fit this description. It is not the high-risk groups which have most effect on population, but pregnant women. In some African countries there is a 20—30 per cent risk of HIV infection, even with no other risk factor than being pregnant, and incubation is six years, not 10 years. Three factors are commonly overlooked which result in underestimating the spread of HIV in Africa: there is much mixing of high- and low-risk groups; women have more sexual partners at younger ages than men (on average the age gap is 10 years); and transmission from man to woman is much higher than vice versa. HIV can have a major demographic effect if seroprevalence reaches about 30%. In some African countries, for example Uganda, prevalence is very close to this after only a few decades of urban spread. In Asia, especially India, HIV is reaching African proportions; in Bombay and Pune nearly one-third of prostitutes were seropositive in 1991. Globally, by the year 2000 there will be 10 million AIDS orphans. The behavioural response to such high mortality is an unknown factor at present. [A report by the International Family Health organisation stated: 1 in 40 African adults is now infected with HIV. These 6 million women and men, and the three-quarters of a million infected children, are unevenly distributed over the continent. In East Africa the real burden of disease and death is only just beginning to be felt, but already AIDS cases make up 80% of the case-load in some adult hospital wards ... 1 in 8 adults in Abidjan now carry HIV1 or HIV2. The burden of associated diseases is overwhelming... Already there are 50,000 AIDS orphans in just one region (Kagera) of Tanzania, and agricultural production in the same area has fallen by 3-20%. Yet only a small fraction of those infected with HIV in any part of Africa have died. From the point of view of costs to the community and health services the epidemic is only just beginning.10 The UNFPA report1 on world population states that the spread of HIV and AIDS is unlikely to significantly alter projected population growth.] Money That Britain receives from developing countries four times more than it gives in aid was the most notable information given by Dr Peter Poore of Save the Children Fund, speaking on SCF policy. The conference took little note of the financial dimension, except to note that $9 billion (of which only $3.5 billion would come from the industrialized world) spent on family planning
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would achieve targets by 2000, and that this is very little, and highly costeffective. [Development aid is a very small proportion of industrialized countries' budgets. Many countries including Britain refuse to meet even the low norms for development aid. Britain's development aid was 8.1 per cent of its military budget in 1990; for the United States the ratio was even lower, at 3.8 per cent; France, Germany and Australia gave 16-17 per cent while Canada, Japan, Norway, Sweden, Denmark, Holland and several other countries gave development aid equal to 25-50 per cent of their military budgets. In Britain development aid as a proportion of gross national product fell from 0.56 per cent in 1960 to 0.27 per cent in 1990.4 Of these very small amounts of development aid, less than 1 per cent is spent on population policies and family planning; this is a reduction on the 2 per cent of aid money spent on population measures in the 1970s.11 Such considerations will influence which of the low, medium, or high UNFPA predictions cf population growth come about. No contributor to the conference expressed conviction that the low prediction, the only one not exceeding the earth's carrying capacity, would come about; meeting even the medium projection will require more governmental committment than exists at present.] References
1. State of the World Population 1992. New York: UNFPA, 1992. 2. Walker A. Health and the environment. Population: more than a numbers game. BMJ 1991; 303: 1194-7. 3. Reproductive Health, a Key to a Brighter Future. Geneva: WHO, 1992. 4. Human Development Report 1992. New York: United Nations Development Programme, 1992. 5. Harrison P. The Third Revolution. London: I B Tauris, 1992. 6. Harrison P. Too much life on Earth? New Scientist 19 May 1990: 28-9. 7. King M. Health is a sustainable state. Lancet 1990; 336: 664-7. 8. Lithell U-B, Rosling H, Hofvander Y. Children's deaths and population growth. Lancet 1992; 339: 377-8. 9. Editorial. Pressure on the eco-seams. Lancet 1992; 339: 1265-7 10. Potts M. AIDS in Africa. Lancet 1992; 339: 238. 11. Potts M. Europe: population concerns. Lancet 1992; 339: 605-6. (5 August 1992)
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