Health Transition Review EDITORS John C. Caldwell Health Transition Centre, ANU, Canberra Shail Jain Health Transition Centre, ANU, Canberra ASSOCIATE Allan G. Hill Harvard University, Boston EDITORS Arthur C. Kleinman Harvard University, Cambridge Stephen J. Kunitz University of Rochester, Rochester Samuel H. Preston University of Pennsylvania, Philadelphia Jon E. Rohde UNICEF, New Delhi Gigi Santow Demography Unit, Stockholm University EDITORIAL Lawrence Adeokun Makerere University, Kampala ADVISORY Moses Kweku Aikins Medical Research Council, The Gambia BOARD Alaka Basu Cornell University, Ithaca Caroline Bledsoe Northwestern University, Evanston John H. Bryant Aga Khan University, Karachi Pierre Cantrelle ORSTOM, Paris Lincoln C. Chen Harvard University, Boston John Cleland London School of Hygiene and Tropical Medicine, London Monica Das Gupta Harvard Center for Population and Development, Cambridge, Mass. Herman L. Delgado Institute of Nutrition of Central America & Panama, Guatemala Bob Douglas NCEPH, ANU, Canberra Aleyya El Bindari Hammad WHO, Geneva Sally Findley Columbia University, New York Julio Frenk Instituto Nacional de Salud Pœblica, Mexico Godfrey Gunatilleke Marga Institute, Colombo Carl Kendall Tulane University, New Orleans Peter Kunstadter University of California, San Francisco Rance P.L. Lee Chinese University of Hong Kong Shirley Lindenbaum The City University of New York David Mechanic Rutgers University, New Brunswick Richard Meckel Brown University, Providence Marvelous Mhloyi University of Zimbabwe, Harare Joyce Lewinger Moock The Rockefeller Foundation, New York W. Henry Mosley The Johns Hopkins University, Baltimore Cynthia Myntti The Ford Foundation, Jakarta Mark Nichter The University of Arizona, Tucson David Nyamwaya African Medical and Research Foundation, Nairobi Patrick O. Ohadike United Nations Regional Institute for Population Studies, Accra I.O. Orubuloye Ondo State University, Nigeria Alberto Palloni University of Wisconsin, Madison Olikoye Ransome-Kuti Federal Ministry of Health, Lagos P.H. Reddy Population Centre, Bangalore Zeba Sathar Population Council, Islamabad Santhat Sermsri Mahidol University, Salaya, Nakornpathom Richard Smith All Souls College, Oxford University, Oxford Andrew Tomkins Institute of Child Health, University of London, London Budi Utomo University of Indonesia, Jakarta Susan Reynolds Whyte University of Copenhagen, Copenhagen Huda Zurayk The Population Council, Cairo PRODUCTION Jeff Marck Health Transition Centre, ANU, Canberra Wendy Cosford Health Transition Centre, ANU, Canberra Sandi Goddard Health Transition Centre, ANU, Canberra ISSN 1036–4005 Published by the Health Transition Centre, National Centre for Epidemiology and Population Health, The Australian National University, Canberra ACT 0200, Australia. Email addresses: [email protected] (Shail Jain) or [email protected] Annual subscription: Health Transition Review, Health Transition Centre, Fax 61-6-249-0740 or [email protected] Publication frequency: April and October. Printing by Better Printing Service, Queanbeyan, NSW Cover design by Graphic Design Unit, The Australian National University Copyright ã 1996 Health Transition Centre. All rights reserved. The copyright owner’s consent does not extend to copying for general distribution, for promotion, for creating new works, or for resale. Written permission must be obtained from the publisher. Preface The papers in this volume were presented at a seminar held in Canberra, Australia in August 1995 to celebrate the distinguished career of the editor of Health Transition Review, Professor John C. Caldwell known usually as Jack. The Symposium was centred on the theme of ‘The Continuing Demographic Transition’, and it brought together demographers, anthropologists, epidemiologists, sociologists, economists, and statisticians who have been influenced by the work of Caldwell and his wife, Pat. That is the common theme which runs through the rich and diverse offerings of this and the other two major publications that have emerged from the seminar.1 Improved understanding of the transitions in demography, epidemiology and health which are taking place at different rates and in profoundly different ways in differing population groups, has become urgent. How else will policy directed towards the stabilization of world population growth be grounded? The papers presented in this volume cover the gamut of issues from sexual initiation, to marriage customs, to women’s education, to life course perspectives, biomedical models of health, the nature of transition research and the social and political environment that surrounds these transitions. Is there a simple story that emerges from all of this? The answer is: not nearly as simple as it seemed when demographers first set out to explain the profound shifts in mortality and fertility that were taking place in the industrialized world in the late nineteenth century. A unifying grand theory has been neither articulated nor postulated. Health, reproductive, educational, and economic decisions by humans are products of the complex interplay of social, biological, cultural and political forces which vary in their emphasis across time and place. What the Caldwells have taught us all is that transition research demands a marriage of the quantitative and qualitative sciences, a willingness to immerse ourselves in the human detail of life decisions, and a capacity then to stand back and place the findings in a broader frame. The papers presented here cross the spectrum of that activity. And they portray a dilemma for population scientists as we approach the millennium. The dilemma is this: how will this smorgasbord of growing understanding be most effectively translated into useful public policy? The evidence is growing rapidly that human numbers are outstripping their ecological niche. The sustainability of our unprecedented levels of life expectancy is being seriously questioned.2 How will the world scientific and research communities deal with these issues in the next century? Will the study of human transitions continue as exemplified here as ad hoc, investigator-driven, and largely intellectual activity, 1 The Continuing Demographic Transition, ed. G. Jones, R.M. Douglas, J. Caldwell and R. D’Souza, to be published by Oxford University Press; The Third World AIDS Epidemic, ed. I.O. Orubuloye, J. Caldwell, P. Caldwell and S. Jain. 2 Climate Change and Human Health, ed. A.J. McMichael, A. Harris, R. Sleef and R.S. Kovats, Geneva: WHO 1996. ii or will there be a coherent effort by the world community to use this and future research systematically to develop population policy? Some of us at the meeting saw the need for this research to move now into high gear, to develop a policy arm and to be housed in a prestigious international institution that could interact freely with national and international governments and population agencies. The John C. Caldwell seminar would not have been possible of course without its central figure, whose seminal contributions to transition theory are now widely acknowledged. But it also depended heavily on the activities of Dr Gigi Santow, a former editor of Health Transition Review, who worked unstintingly to ensure the intellectual integrity of the program. It also rested on a range of sponsoring bodies who provided support for authors to attend the meeting. For that we sincerely thank the Ford Foundation, the Rockefeller Foundation, the Andrew W. Mellon Foundation, the Academy of the Social Sciences in Australia, the Australian Population Association, the Australian Agency for International Development (AusAID), the Commonwealth Department of Human Services and Health, the International Union for the Scientific Study of Population, the Overseas Development Administration, the Population Council and the Research School of Social Sciences and the National Centre for Epidemiology and Population Health at the Australian National University. R.M. Douglas G. Jones R.M. D’Souza Supplement to Health Transition Review Volume 7, 1997 Health Transition Review, Supplement 6 1996, 1-18 Fertility transition in England and Wales: continuity and change * Dov Friedlander and Barbara S. Okun Hebrew University of Jerusalem Abstract The focus of this paper is whether the transition from high to low fertility reveals continuity or discontinuity with the past. Our analyses of districts of England and Wales over time reveal an overall picture of continuity. Specifically, we show that (1) a substantial proportion of districts experienced pretransition variations in marital fertility that were so large that they are suggestive of deliberate fertility control; (2) the changes over time in the distributions of marital fertility levels and the relative importance of marital fertility levels to the determination of overall fertility levels were gradual and smooth; (3) the proportion of districts dominated by marital fertiliity variation, as opposed to nuptiality variation, increased gradually over time, and both marital fertility and nuptiality variations were present in all periods considered; and (4) there are important relationships between changes over time in marital fertility and socio-economic variables in periods both before and after the transition. The last conclusion is based on our estimated equations from the pooled cross-sectional, time-series data. Moreover, these estimated equations reveal relationships between changes in specific explanatory variables and changes in marital fertility