Population Growth Rate CBR-CMR

Population and Global Health

Stephen Gloyd, MD, MPH

GH 101

“One stinking hot night in Delhi” (description of the population problem) “As we crawled through the city [in a taxi], we entered a crowded slum area. The temperature was well over 100, and the air was a haze of dust and smoke. The streets seemed alive with people. People eating, people washing, people sleeping. People visiting, arguing, and screaming. People thrusting their hands through the taxi window, begging. People defecating and urinating. People clinging to buses. People herding animals. People, people, people, people. As we moved slowly through the mob, hand horn squawking, the dust, noise, heat, and cooking fires gave the scene a hellish aspect. Would we ever get to our hotel?”

Paul Ehrlich, ‘The Population Bomb’ 1960 Response: Mahmood Mamdani

“The fact is that a hot summer night on Broadway in New York or Picadilly Circus in London would put Ehrlich in the midst of a far larger crowd. ….. …what disturbed him about the crowd in Delhil was not its numberss, but its ‘quality’ – that is, its poverty. …to talk, as Ehrlich does, of ‘overpopulation’ is to say to people: you are poor because you are too many.’

Mamdani, The Myth of Population Control, 1972 Population Terms

Crude Birth Rate # births/1000pop (or women)

Crude Mortality Rate # deaths/1000pop

(General) Fertility Rate # births/15-44 women

Total Fertility Rate avg # children/woman in lifetime

Population Growth Rate CBR-CMR

Dependency Rate Pop <20 + Pop >65/pop 20-64 History of Approaches to Population

• Encouragement of population growth • Malthus 1798 – anti-public assistance for poor • Eugenics movement (USA – 1900-30) • Population crisis (1960-1980) • Debates about population-health-poverty- environment – Mexico City Conference 1964 – Cairo Conference 1994 – Clinton-Gore policies (Homer-Dixon, Kaplan) – Projections of late 2002 – Bush policies (“Global Gag Rule”) – Obama’s policies Population, poverty & hunger • India has 2x more cropped land/person than China • Bangladesh has 2x more farmland/person than Sri Lanka • Honduras has more farmland than Costa Rica

Population and Pollution • Average American consumes 30x more than average African • African growth rate would have to be 10x higher to be a problem for world’s non-renewable resources • Brazil: 2% own 60% of arable land. Logging and cattle ranching patterns reflect land ownership patterns Is population a root cause of…

• Poverty? – Poor families have more children – Poor countries have high growth rates

• Hunger? – Famines in India, Bangladesh, Ethiopia – World production of food vs. population

• Environmental degradation? Contributors: – Rich areas (fossil fuels, consumption, waste) – Poor areas (wood (fuel) – erosion) Basics: Empirical evidence exists that: • Population is growing rapidly (esp. in developing countries) • Migration to urban areas has increased everywhere • Poor countries have higher population growth rates • Poor families have more children • Global environment is compromised by pollution & warming

Questions for policy: • Are population growth, large family size, high population density root causes of poverty, hunger, pollution? • Is urbanization a root cause of poverty hunger, pollution? • Does family planning reduce population growth? • Does family planning improve health and development?

WORLD POPULATION HIGHLIGHTS THE WORLD AT 7 BILLION

The Four Phases of Demographic Transition Are Evident Today Around the World. In the parish of Mouy, north of Paris, there were 47 burials recorded in 1693; in 1694, the number jumped to an appalling 262. This is a dramatic example of life during Phase 1 of the demographic transition (albeit a somewhat modern one compared to the 50,000 years of human existence that preceded Phase 1). A rise in the price of grains meant more people could not afford food, a situation that nearly always led to excessive mortality, as happened in Mouy. In Phase 2 of the transition—roughly the beginning of the Industrial Revolution—death rates began to fall more regularly, although the preference for larger families may have remained for a time. Next, increasing urbanization lessened the need for children even as early public health measures improved life spans. Now the transition was really underway. By the 20th century, the development of modern medicine and the desire to limit family size combined to cause the low death rates and very low birth rates we see today. That, at least, is what happened over the centuries in Europe and North America. Most developing countries arrived in the 20th century still in the fi rst phase of the transition. In the aftermath of World War II, however, the benefi ts of public health and modern medicine became available to them in a comparatively short period of time. Mortality fell with unusual rapidity but the desire for large families remained. Then, with mounting concern over record rates of population growth, birth rates did begin to fall in many countries. Today, we can fi nd examples around the world of all four stages of the transition.

The Classic Phases of Demographic Transition Birth Rate Death Rate

PHASE 1 PHASE 2 PHASE 3 PHASE 4 PHASE 1 High Birth Rate, Declining Birth and Birth Rate Approaching Low to Very Low Afghanistan 44 16 Fluctuating Death Rate Death Rates Replacement (2.1) Birth Rate, Very Low Uganda 46 12 Death Rate Zambia 46 15

PHASE 2

Ghana 31 8

Birth Rate Guatemala 30 6 Iraq 35 6 Natural Increase PHASE 3 India 23 7

Gabon 27 9

Death Rate Malaysia 21 5

PHASE 4

Brazil 15 6

Time Germany 8 10 NOTES: Natural increase or decrease is the difference between the number of births and deaths. The birth rate is the number Japan 8 9 of live births per 1,000 population in a given year. The death rate is the number of deaths per 1,000 population in a given year.

SOURCE: (for burials in 1693 and 1694): E.A. Wrigley, Population and History (New York: McGraw Hill, 1969).

The World Is in the Midst of Its Most Rapid Population Growth in History. Today, the world is adding the largest numbers to its population than in any time in history. Despite the fact that the annual population growth rate has declined to 1.2 percent per year, world population grows by about 83 million annually. If the same growth rate had applied in 1950, only 30 million people annually would have been added to the world total. While declines in birth rates have been virtually universal across countries, the pattern of decline has been very variable. In some countries, birth rates have fallen below two children; birth rates in other countries have decreased to medium levels or have barely begun to decrease. Population projections assume that birth rates in developing countries will decline—smoothly—to two children or fewer (this PRB data sheet incorporates that assumption). Both the sixth billion and seventh billion were reached in the same number of years: First Classic Stages of DemographicAll of Human History (ca. 1800) a record 12. The eighth Billion billion may also take 12 Second 130 Years (1930) years but only if birth Transition rates decline according to Third 30 Years (1960) projections.

Fourth 14 Years (1974)

Fifth 13 Years (1987)

Sixth 12 Years (1999)

Seventh 12 Years (2011)

Eighth 12 Years (2023) ?

SOURCES: Population Reference Bureau estimates and projections (1800 and 2023) and United Nations Population Division.

Note: Natural increase is produced from the excess of births over deaths.

W ORLD PO P ULATION HIGHLIGHTS FOCUS ON AGING Today, Global Population Adds Another Billion at Record Rates. At some point around 1800, after untold millennia of human history, global population reached its ﬁrst billion. The world’s population now grows by 1 billion about every 12 years. The 20th century began with 1.6 billion and, at the end of that century, those two numbers had simply reversed to 6.1 billion. If birth rates continue to decline in developing countries, the increase to 8 billion could take slightly longer.

First All of Human History ca. 1800 Billion

Second 130 Years (1930)

Third 30 Years (1960)

Fourth 14 Years (1974)

Fifth 13 Years (1987)

Sixth 12 Years (1999)

Seventh 12 Years (2011)

Eighth 13 Years (2024)

SOURCE: Population Reference Bureau estimates and projections; and UN Population Division, World Population Prospects: The 2008 Revision (2009).

As Developed Countries Undergo Aging and Little Growth in Population Size, Developing Countries Remain Young and Growing. The population “pyramid” of the developed countries clearly shows the decline in the number of young people as a result of low birth rates. The two pyramids provide a comparable picture of the developed and developing countries in the size of their respective populations and age structure. In some DEVELOPED COUNTRIES DEVELOPING COUNTRIES Age Age developed countries, the Less Developed Countries85+ HaveMales More Females 85+ Males Females size of the youngest age 80-84 80-84 group is barely more than 75-79 Young People Relative75-79 to Elderly half that of their parents’ 70-74 70-74 age group. When the two 65-69 65-69 population pyramids are 60-64 60-64 compared, it is obvious 55-59 55-59 that virtually all future 50-54 50-54 world population growth 45-49 45-49 will take place in the 40-44 40-44 developing countries. But 35-39 35-39 the amount of growth 30-34 30-34 these countries will expe- 25-29 25-29 rience depends upon the 20-24 20-24 15-19 15-19 degree to which couples 10-14 10-14 in those countries 5-9 5-9 choose to reduce family 0-4 0-4 size and have access to 300 200 100 0 100 200 300 300 200 100 0 100 200 300 family planning services. Population (millions), 2010 Population (millions), 2010

SOURCE: UN Population Division, World Population Prospects: The 2008 Revision (2009).

Source: United Nations Population Division, World Population Prospects: The 2006 Revision, and Population Reference Bureau (2010) Relationships between Population, Health and Poverty Are there causal relationships between: 1. Rapid population growth 2. High population density 3. Large family size and health and poverty indices?

Overall answer: – Variable associations (positive and negative) – Usually small quantitative relationships, if any – Not a dominant effect

Population Density Population Density (pp/km) (among countries over 20m pop)

Poorest 1997 2010 Richest 1997 2010 Ethiopia 34 75 USA 25 32 Bangladesh 688 1033 Japan 322 335 DRC 13 28 Germany 225 231 Uganda 86 139 France 110 114 Myanmar 62 71 UK 230 255

Other countries 1997 2010 Vietnam 223 265 Netherlands 351 400 India 227 373 China 107 140 Haiti 192 360 Kenya 33 70 Nigeria 104 171 Kerala (30m) 819

Source: United Nations World Population Prospects (2004 revision). Data is for 2005. Global Population Density

Source: http://sedac.ciesin.columbia.edu/wdc/map_gallery.jsp Is population density a causal factor in poverty or malnutrition?

• High population density might potentially lead to poverty, malnutrition, or poor health by decreasing the amount of arable land for farming, thus reducing available food.

• Also, increased density might increase pollution and reduce fuel biomass Ø No analysis has demonstrated a causal link.

Note: Many of the densest populations are well off rich countries in Europe or Asia. Pollution is not consistently associated with high population density (e.g., USA) Family Size Is large family size a causal factor in poverty?

Theoretical arguments, pro and con: Large family size can lead to poverty by • increasing intra-household inequality, by decreasing the ability of women to work for pay • decreasing opportunities for education and health of children • by reducing the family's ability to save and invest to protect itself from unexpected decreases in income.

Large family size can operate to reduce poverty by • providing resources to a resource-poor household (from family chores to income generation) • providing security for old age • enlarging the pool of potential generators of wealth for families who have income insecurity. Why do poor families have many children?

1. Children as resources: labor, income, insecurity 2. Powerlessness of women, men 3. Son preference 4. Religion, social class, culture 5. Lack of health services

Women of Childbearing Age and Fertility Worldwide

3 6

2.0 2.0 2 4 1.8

Billions 1.3 1 0.9 2

0.6 woman per Children 1

0 0 1950-1955 1970-1975 1990-1995 2010-2015 2030-2035 2045-2050

Women 15 to 49 Average number of children per woman

Source: United Nations, World Population Prospects: The 2004 Revision (medium scenario), 2005. Is large family size a causal factor in poverty?

Evidence: • Studies from developed countries generally find evidence of a negative impact of family size on child well-being • Empirical studies from developing countries is mixed – both positive and negative impacts (Ahlburg, Pop Growth & Poverty1994) • Extra birth (twins) reduces schooling of siblings 17-34% (Rosensweig, JPolEcon 1990) • Large families (older children and relatives) provide additional resources and level out fluctuations of income in poor families • Small impact of family size compared to education, assets, family income (most authors) Population Growth

Developing Regions Make Up an Increasing Share of World Population

World Population (in Billions): 1950-2050

Source: United Nations Population Division, World Population Prospects: The 2006 Revision, and Population Reference Bureau (2008). Projected Population Change

Percent Population Change, 2005-2050

Source: Population Reference Bureau, 2005 World Population Data Sheet. Less Developed Countries Have More Young People Relative to Elderly

Population by Age and Sex, Less Developed Countries: 2008

Source: United Nations Population Division, World Population Prospects: The 2006 Revision, and Population Reference Bureau (2008) Population Growth - some studies

• Regression analysis of 22 countries from 1960-1985: Pop growth was not associated with changes in poverty, using different measures of poverty, models, and time periods (Squire, AmEcRev 1993)

• No evidence of wage decrease during 60-80 population growth (accommodations –land reform, land inputs, increased non-agricultural employment, development of human capital of poor)

• Past population growth = higher GNP/capita growth; recent pop growth = lower GNP/capita growth difficult to assess cause and effect (Johnson,Lee, Pop Growth&Devt 1987) Other studies/observations re Population Growth

• Common property decrease from 1950-80 (firewood, free ranging for animals, water, building materials) – but result of government policy as much as growth (Jodha 1990)

• Decrease educational expense per child in countries with larger population growth – but mostly related to economic adjustment and social policies (Cox, Jiminez) Thus, Causal effect of rapid population growth and poverty is basically unclear

“It is likely that …these studies are too unreliable for significant inferences to be made, except perhaps for two: 1) that population is not a dominant effect—….and 2) that no analyses have yet been conducted that fully meet contemporary econometric standards.” Robert Cassen, 1994, ODC

Policy Implication: “…If family planning programs are driven by demographic goals (as they frequently have been), they will often fail to address women's reproductive health problems and actually diminish the prospects of the demographic goals being met.” Summary

Are there causal relationships between: • High population growth • Large family size • High population density Ø and health and poverty indices?

Overall answer: • Variable associations (positive and negative) • Usually small quantitative relationships, if any • Not a dominant effect

Does birth spacing improve health?

Birth spacing (>2 yrs) (estimates from PRB, studies not documented) • Reduces mortality of second child by 2x • Can prevent 25% of infant deaths • Can prevent 25% of maternal deaths (20% if meeting just existing demand) BUT, no change in risk of death • Doubling birth intervals increases birth weight 3-6%; postponing birth one year increases BW 1.4-3.2% Does family planning (in general) work? Family Planning = Conscious effort of couples to regulate the number and spacing of births through artificial and natural methods of contraception.

Among users compared to non-users • Reduction in child mortality (~25%) • Reduction in maternal deaths (~25%)

How? • Reduces maternal depletion and teen childbearing • Reduces abortions (20 m/yr resulting in ~75,000 deaths) • Condom use prevents HIV/AIDS • Gives women (and men) power to choose when to be pregnant Source: White Ribbon Alliance for Safe Motherhood Use of contraception

Population control programs:

“But they were so nice, you know. And they came from distant lands to be with us. Couldn’t we even do this much for them? Just take a few tablets? Ah! Even the gods would have been angry with us. They wanted no money for the tablets. All they wanted was that we accept the tablets. I lost nothing and probably received their prayers. And they, they must have gotten some promotion.”

Khanna Study, Mamdani, “The Myth of Population Control” 1972 Different Patterns of Contraceptive Use

Percent of Married Women Using Contraception, Selected Countries

N.A. – Data not available. Sources: Demographic and Health Surveys and United Nations Population Division, Population Reference Bureau Percentage of Women Giving Birth 100 by Age 20, by Level of Education

75 None Primary Grade Secondary Grade

Africa Latin America, Asia Caribbean

(U.N. Population Fund. State of the World Population 2003. http://www.unfpa.org/swp/2003swpmain.htm ) Application of Family Planning Programs

• Large unmet need (Mozambique – 80% want to “rest” between pregnancies) • Current demand 150 million women –worldwide • Low cost (~$2/cap/yr) • Works within health care system • Donors like it

Source: White Ribbon Alliance for Safe Motherhood Different Patterns of Fertility Decline Fertility Patterns for Selected Countries: 1950-2010

Sources: United Nations Population Division, World Population Prospects: The 2006 Revision; Population Reference Bureau; and Korea National Statistics Office. Underlying Intermediate outcomes & Desired conditions symptomatic issues outcomes

Lower pop- density Lower fertility

Reduced teen Family pregnancy planning

Birth spacing Reduced Smaller Maternal Mort family size

Education

Poverty Reduction

Family income

Family Reduced National Income Nutrition perinatal & (GNP/cap) child mortality

Access to Water, San, PHC, Hygiene Reduced prenatal, birth, disease (HIV, child care malaria, etc) Food and Hunger Global Cropland Source: http://sedac.ciesin.columbia.edu/wdc/map_gallery.jsp Myths regarding hunger (1) from “Food First”

1. There is simply not enough food 2. Droughts and other natural conditions beyond human control cause famine 3. There are too many mouths to feed 4. Pressure to feed the world is destroying the environment

5. The green revolution is the answer 6. Efficient production requires large scale farming Myths regarding hunger (2)

7. A free market will alleviate hunger 8. Free international trade would increase exports of poor countries to allow importation of goods to alleviate hunger 9. The poor are too hungry, too passive to revolt against the conditions which make them poor and hungry

10. More international assistance will help the hungry 11. People in rich countries benefit from the conditions which create poverty and hunger in poor countries

12. Societies which have eliminated hunger also eliminate freedoms Climate Change & the Environment Source: http://sedac.ciesin.columbia.edu/wdc/map_gallery.jsp

Developed Countries Consume More Third World population growth and the environment – a bum rap? Health Impacts of Climate Change

Thank you!