Still Ticking

In 1798, Malthus penned "An Essay on the Principle of Population," arguing that human populations tend to increase faster than their food supplies. The Malthusian vision is a brutal demographic system of checks and balances: A population incessantly outraces its capacity to sustain itself, suffering famine, misery and massive death. The idea that birth—the driving engine of population growth—could lead to massive famines and death fixed itself in the human imagination.

It's not difficult to envision cataclysm when you examine global population throughout human history. For centuries, the number of people in the world changed little. Population was limited by infectious disease and subsistence living. Then, in the 1600s or so, population began to arc upward. Essentially, it took all of human history until 1800 to reach 1 billion people. Then it took just 130 years to reach the second billion, 30 years to make the third... Since 1950, global population has more than doubled to its current 6.6 billion today.

The 20th century's spike in global population was undoubtedly aided by public health. Water treatment, vaccines, antibiotics and improved nutrition and hygiene saved countless lives and doubled life expectancy in many countries. But by the 1960s, people began worrying about a "population explosion" that would unleash a global Malthusian catastrophe. In The Population Bomb, the zeitgeist's central text first published in 1968, author Paul R. Ehrlich warned, "The birth rate must be brought into balance with the death rate or mankind will breed itself into oblivion." Even mainstream demographers in the 1970s predicted global population would reach 20 billion or so by the mid-21st century. (Current estimates forecast 9.2 billion people by then.) But a strange thing happened on the way to global disaster—birth rates began falling and the population story became more complex.

From today's perspective, Ehrlich and others' rants have a whiff of quaint hysteria—especially the predictions about developed countries. Ehrlich warned in The Population Bomb that Japan would double its 1965 population of 100 million in 63 years, but we now know Japan will never get close to 200 million people. In fact, its population will likely retreat from its current 127 million to 100 million by 2050. Russia's population is expected to drop by 23 percent by then to 109 million. Meanwhile in much of Europe, fertility rates have fallen below the replacement level, meaning the average number of children born per woman is below the 2.1 considered necessary for a constant population level.

And tumbling fertility rates were not exclusive to wealthy countries. Many other countries in Asia and Latin America have made what population experts call the "demographic transition," shifting from high birth and death rates to low birth and death rates. In Bangladesh, for example, the total fertility rate of 6.6 children per woman in 1970 has fallen to 3 (though it has stalled at about 3 for more than a decade). Iran's total fertility rate plummeted from 6.5 in 1980 to 2.0 today.

There is no single reason for the falling fertility rates in so many different countries, but demographers point to changes in women's status and increased employment opportunities and education, older ages of marriage, more and better family planning choices, aggressive policies in countries like India and China, and so on.

As the fertility trends became manifest in the late 1970s through the 1980s, population issues slipped off the global health radar screen. (One indicator: Population is not mentioned among the UN's eight Millennium Development Goals, which seek to reduce poverty, improve maternal and child health and achieve other goals by 2015.) Yet global population overall continues to grow and populations of specific regions are experiencing sharp rates of increase. Even the lowest estimates predict that by 2050 there will be more than 8 billion people on earth. "You think, what is the world going to be like with roughly two more Indias on earth," says Duff Gillespie, a professor of Population, Family and Reproductive Health (PFRH) and formerly USAID's most-senior career professional in global health. "We are not at the catastrophic stage yet, but we potentially are approaching it unless we do something.

"The world is much more complex than the 'population bomb or no bomb,'" he says. "Static or declining population presents real problems for Japan, for Germany, et cetera, that have to be dealt with. That's obviously a markedly different problem than that faced in Nigeria, Pakistan or Ethiopia where you have the frightening prospect of very poor countries having twice as many people as they now have in your lifetime. In a place like Ethiopia, it's right on the cusp. In just about 28 years, they will go from 75 million people to 140 million, and you think, How is that going to work?"

As burgeoning populations in Ethiopia, Nigeria, Pakistan and elsewhere can attest, the population problem did not magically resolve itself. "The issue of rapid population growth is still important, it's just become more important for certain parts of world," says Amy Tsui, director of the Bill and Melinda Gates Institute for Population and Reproductive Health at the Bloomberg School. "Sub-Saharan Africa and parts of the Middle East are relatively impoverished and have low rates of female literacy. When you have poor gender equity, that also challenges solutions to managing reproduction. Those places are going to grow quickly. Our attention is now drawn to those regions."

At special risk are countries with a large percentage of young people yet to enter childbearing years—such as Kenya, Pakistan, Yemen and Laos. Demographers know that such states have "population momentum" that can launch a baby boom leading to sharp growth in population in subsequent decades. Even countries with a natural annual increase of 2 percent must prepare for dramatic changes in a short time. Laos' annual growth rate of 2.4 percent means that its population will double in just under 30 years. Niger's 3.4 percent rate will double its population in just over two decades.

Demographers take the long-term view. How many mouths will need to be fed in 50 years? Will there be adequate schools for the population? How do you secure a sustainable population mix of productive adults who can provide for a dependent population of the very young or the very old?

But population has immediate effects on the health of the society and the individual. "Anybody doing anything in international health has to be concerned about population. Patterns of fertility affect how well any of our interventions do," says Peter Winch, an associate professor of International Health. "In some ways if we ignore population issues, then all the work we do is being undone."

To reduce mortality of children under 5, for example, the standard public health tools include safe drinking water, good hygiene, better nutrition, adequate vaccinations and so on. But another key method: birth spacing. Increasing the time between births in a family not only reduces the number of children born to each woman, but it enhances a child's likelihood of survival. With finite resources, having fewer children means each child is likely to have more food, health care and school fees available for him or her. "Everything works better if you have birth spacing and a smaller family size," says Winch, MD, MPH '88.

The most immediate benefit of reducing fertility is that it saves women's lives. To communicate this idea to the developing country health professionals he trains, W. Henry Mosley asks them what is the number one cause of maternal mortality.

"They say eclampsia or hemorrhage. I say, 'It's pregnancy. You can't have maternal death unless a woman's pregnant,'" says Mosley, the former chair of the School's Department of Population Dynamics (a forerunner of what is now Population, Family and Reproductive Health). He notes that up to half of pregnancies in some countries are unintended. Robust family planning programs, he argues, would reduce maternal mortality. "We could save women's lives if they were not having so many children," he says. "If half of all pregnancies are unintended why are [countries] investing so much money in building maternity hospitals? It's like saying, 'Thousands of kids are dying of measles; we need more hospitals.' I say, why not just vaccinate them?"

The case against unfettered population growth seems obvious, so why aren't population issues dominating global health efforts? The short answer is culture, history and differing perspectives within the academic community.

In some cultures, children (and sometimes wives) are seen as signs of wealth. "In the Sahel, children are so valued in the culture. People love kids, and that's a good thing," says Winch. "People don't have other sources of wealth. If you have a 401(k), okay, you can have fewer kids. But if children are your one source of wealth, how do you cut back?" In other contexts, parents consider children a means of support, says Mosley. In many developing countries, "they say, 'One mouth, but two hands'—meaning that they produce more than they consume. And the culture depends on that," says Mosley, a PFRH professor.

"One mouth, two hands" sheds a cultural light on why population issues are a sensitive subject: They can strike at the heart of all that an individual values in life, a family's sense of self and a nation's determination to be vital and growing.

In Uganda, President Yoweri Museveni has called for women to have more children, arguing that his country is underpopulated and that more consumers would mean greater markets and a stronger economy. Such policies ignore the desires of women to have fewer children. The measure of women who want to postpone or limit their births but are not using contraception—"unmet need"—is falling in most countries, but in Uganda it has reached 40 percent and is one of the few countries where unmet need is still increasing, says Tsui. "They are ignoring one of the fundamental health needs," she says. "I just don't understand how in the face of these indicators one can say that it is important to continue to have more births. It's almost like they're finding a way to legitimize those unintended births."

Some leaders in sub-Saharan Africa and other regions consider family planning initiatives sponsored by wealthy countries as "white man's medicine being pushed down their throats," says Tsui, PhD. "For some reason, people see family planning as an exogenous policy that donors are trying to impose on these countries."

While most leaders do support family planning as a means of tempering population growth, they find it difficult to shift scarce resources to family planning when besieged by immediate needs such as prevention and treatment for HIV/AIDS, malaria and other infectious diseases as well as demands for better primary care, immunization coverage and other health programs. "Most of the leaders in these countries have family planning policies. What they don't have are the programs and the support of donors," says Gillespie, PhD. "This is one of the consequences of the U.S. not continuing its leadership role in this area."

The U.S. government is still the leading donor for international family planning efforts, but its support has dropped significantly from its high point in 1995. Its priorities have shifted in recent years to resonate with domestic politics: supporting abstinence programs while withdrawing funds from organizations that provide abortion care or help sex workers. "Everything gets a bit diluted so we don't see as much focus on family planning," says Tsui.

She also notes that funding for academics studying population issues has dropped in recent years as well. With dimmer prospects for future grant support, fewer students are willing to gamble their careers on population issues. This is reflected in curricula as well, as fewer demography courses are offered. "If you are being trained in a U.S. university, you won't find too many courses that address population overall or the formal demography behind it," says Tsui. "The consequence is that most people don't know why a population grows." (An informal faculty group that includes PFRH Professor Stan Becker, Tsui, Winch and others are working to reverse this trend at the School.)

Yet another obstacle to greater action on population issues is debate within the global health community about the propriety of and tactics for reducing population growth rates.

On one hand, Stan Becker states that the only sustainable population growth rate is zero. "Is rapid population growth a problem? In the long term, definitely yes," says Becker, PhD. "We're adding about 200,000 people per day to the world. People are nice, but, you know, in a finite planet, that can't go on forever."

For David Bishai, however, responses to high growth rates are a question of perspective. "In terms of environmental impact, every birth is a pox on the planet. If you're looking from the perspective of nonhumans—from a chimpanzee—every [human] birth is surely a bad thing, but it's not from the perspective of the parents," says Bishai, a PFRH associate professor.

He disputes the notion that high fertility rates in a country are automatically cause for alarm. "The ideal birth rate for a country is the one chosen by the people of that country," Bishai says. "Just as we want individuals to reach their potential, we should want populations to develop their potential."

He also warns against the implicit argument that reducing fertility leads to a surging quality of life. "You can't make a country rich by flying in condoms and contraceptives," says Bishai, MD, PhD, MPH. Nor does he advocate sharp reductions in a population's fertility. Doing this too quickly may ease a country's burden in the near term, but it also makes for a narrow base in the country's population pyramid: too few young people supporting too many old people. "No one in the '70s figured out that if you go around the world reducing fertility, you only have a temporary effect on the dependency ratio," says Bishai. "Like Malthus, they only saw the front end of a decline in fertility. You only buy yourself a 50-year demographic window. Then you have the same proportion of dependent folks—they just happen to be old dependent folks."

He believes the Malthusian "poverty trap" is an over-diagnosed syndrome and that few countries are genuinely at risk. To Bishai, choosing how many children you want to have is one of the most basic of human rights. The world's desperately poor people have more children because they are adapting to an environment in which some may not survive to adulthood, few will receive the education required to lift themselves from poverty, and many hands are needed for physical labor. He decries an attitude he detects among some researchers that "people can't pick their right birth rate" and need U.S. academics to pick it for them.

Gillespie agrees that approach simply doesn't work. "You can't go into a country and say, 'You have a population problem because there's too many of you,'" notes Gillespie. "It's not only inappropriate but it's going to backfire. It has to be shown that it is beneficial for themselves to begin to address this."

Family planning, say Tsui and others, is not about forcing countries to reduce their population but helping individuals—especially women—achieve what they want. In 1960, just 7 million couples in the developing world were using contraception. That number has increased to more than 650 million today. "You can't call that coercion," says Tsui. Even with that increase, more than 120 million women in developing countries today are in need of family planning services.

"That absolutely, definitely is a problem," says Bishai. "The common ground is asking people what they need and helping them get it. You don't tell people what they need. I believe in family planning and I'm trying to make it better [through my research], but I also believe communities know what they want. It's one of the things that I credit to Carl Taylor [who founded the School's Department of International Health]: Get out there and listen."

The point, say Tsui and others, is that those conversations need to be happening more frequently and with more countries because population issues are legitimate and even necessary topics for international discussion. "Nigeria's population is spilling into Ghana and causing social problems. Do the Ghanaians have the right to say something about Nigeria's population growth rate? I think so," says Amy Tsui. "I'd like to know how Nigeria plans to accommodate the next 140 million people when they already cannot provide a humane living situation for their people now."

Family planning is not the only means of slowing population growth. Making it easier for women to receive an education and join the workforce, expanding vaccination and other programs to reduce child mortality, encouraging breastfeeding (which has a contraceptive effect) and delaying marriage—all can influence fertility rates.

The challenge is in working with individual countries to acknowledge population's role—negative or positive—in their destiny. As Henry Mosley, MD, MPH '65, says, "The people on the ground own the problem. They ought to own the solution."