MCDB 150: Global Problems of Population Growth

Lecture 14

 - Demographic Transition in Developing Countries


By 1950, in most of the underdeveloped world, mortality had fallen to about half its pre-modern rate. The birth rate, however, had remained high and, by 1950, was about twice the death rate. For the rest of the century, both rates fell dramatically and in parallel, maintaining the gap. The enormous excess of births over deaths in this period is known as ‘the population explosion.’ By 1990, the world population was growing at almost 90 million a year. Comparing the Demographic Transition in Europe and in the currently developing countries, the latter started 100 years later at a much lower economic level, fell from much higher birth and death rates, occurred much faster and with a much higher population growth rate, and added vastly more people. The developing countries saw the benefits that had accrued to the West as a result of the transition and then rapidly appropriated it for themselves. But while European countries may have quadrupled their population over 200 years, third world countries grew by as much as ten times in a much shorter period and they are still growing at a rapid rate. The problems of this rapid growth (still about 80 million a year) abound. The traditional scourges of starvation (9 million deaths a year), disease (AIDS, Tuberculosis, Malaria – all claim between 1 and 2 million deaths per year) and war (Hiroshima and Nagasaki atomic bombs with approximately 200,000 deaths) are all far too small to stabilize population. People in developing countries who want to limit their fertility, are often afraid of contraceptives (especially side-effects) and yet are willing to undergo horrendously dangerous illegal abortions to avert a childbirth.

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Global Problems of Population Growth

MCDB 150 - Lecture 14 - Demographic Transition in Developing Countries

Chapter 1. Introduction [00:00:00]

Professor Robert Wyman: You’re going to get more numbers today. I know you–how many love numbers? You can’t live without numbers. What did I tell you was the traditional, before modern times, death rate? A number you should keep, or birth rate, it’s the same–about per 1,000? About 40 to 50 per 1,000 is the birth and death rate at a life expectancy of 20 years, that means 1/20th of the people die every year and so you need 50 out of 1,000 births 1/20th of your people to be births; so births and deaths, in what we call primitive times, which might mean up to the Napoleonic Revolution, almost is 40 to 50 births and 40 to 50 deaths a year.

Now here is modern times. We’re starting in 1950 in all of these graphs and coming in the period of the popular–main–beginning births of the population explosion 1950 to 1990 in all these cases. And here are the various parts of the world and you’ll notice that this is the death–I’m sorry the birth rate is 50, birth rate is 43 or something 42, 43, 45, 45. That 1950 the birth rate is at approximately its level for centuries way back. We know that not too much before this time since population was not growing until some–a little bit before this time that the death rate must have been the same, so the death rate was also 40 to 50 people.

Look what happened. By 1950 the death rate is already down to half of its traditional level, even in Sub-Saharan Africa it’s almost reduced to half; in Central America, the Caribbean, less than half; South America less than half; China about half; South Asia about half; Southeast Asia about half. In most of the world by the 1950s the birthrate was still extremely high, but the death rate had come down to half of what it had always been.

What was going on is that these countries were almost all still under colonial rule with the exception of South America, which might be a reason why it’s even better. And, among all their faults, the colonialists did institute basic sanitation, basic public health, basic public order and they stopped a lot of the warfare between communities. They imposed a lot of violence upon the people but that was apparently much less then the violence that local communities imposed upon each other in the pre-colonial era, so the death rate was down by the 1950s.

Sometime in 50s, around 1950, the birth rate started coming down in all those countries, and even though the birthrate starts at these very, very high levels they come down almost everywhere with of course the exception being Sub-Saharan Africa, and you’ve read about why that is and I keep saying that almost everything we say, Sub-Saharan Africa is an exception to the rate. Even though the death rate was down, the birth rate didn’t change much, but in every other part of the developing regions of the world, the birth rate and the death rate came down approximately in parallel with each other.

Of course the difference between that birth and death rate is population increase - and this is the heyday of the population explosion. Remember this is per 1,000 so it’s a percent kind of a number, so as the population grows the number of people represented by this percent cap grows and grows, and grows, and so this explains the graph I showed you last time, or two times ago. Starting again in 1950 to 1990, the number of people added each year just keeps growing, with one blip and you’ll see later in the course, I’ve shown you that blip before, but we’ll discuss what that blip is. The data for the individual regions of the world and this all fits together, makes sense.

Now we’ve been through the European population story, and again we saw that, not always but mostly, the death rate fell first and then the birth rate fell and Europe went through a population explosion. To say this story the way I’ve been telling you, no differences, that the third world is just going through exactly what Europe went through, but it isn’t true. Let’s compare two of the fertility transitions. This is Sweden and this is Mexico, and you’ll notice that Sweden has birth and death kind of hanging around until maybe here, until 1860s, and that’s just what the Princeton Project found out that the really serious decline happened somewhere in this 1870 region, and then the death rate declines rather continuously on through the time, and the birth rate declines. This starts around 1870.

Mexico’s decrease starts around 1970. So between what we now call the developing countries or the third world countries, about 100 year difference between when Europe started its transition and when the developing countries started their transition. Now 100 years may seem a lot to you, but in the course of human history, since these numbers had been going on forever, 100 years is a very, very short time. Another difference you should note is–Hang on, I just fixed this. Usually that’s all that required I hope. Nope. Anybody have a laser pointer by any miracle? All right, we’re going to have a little bit of trouble today but I think you can figure things out.

Notice that the levels of everything there are lower in Sweden, that Sweden starts and the European countries generally start at a lower level of births and a lower level of deaths, so they were already, by the time that their serious transition starts, they’re already quite a ways down compared to where Mexico starts. Notice that the deaths and the births are much higher in Mexico than in Europe.

Now those are important, but notice the gradualness of the decline here. That Sweden had a long time to adjust to these changes, whereas, look at the drop in the death rate in Mexico. Boom! Basically all of a sudden and then give it a generation, look at the drop in the birth rate. That’s the most amazing thing, how rapidly things change in the developing world, compared to the way it changed in Europe. Because of this rapidity of this decline and a natural delay here, whereas in Sweden that might be the delay, the delay means because of the rapidity of the decline, that the difference now between births and deaths is this huge amount compared to a much smaller amount here. Europe never had to cope with the rate of increase, the number of people added every year, the percentage of the population, never had to cope with anything like what the currently developing countries had and that’s a result of the rapid drop.

The other thing to note, of course, is that by this time, the births and the deaths in Sweden are essentially equal, and Sweden’s population is not growing anymore and that as you heard from Dr. Teitelbaum’s lecture, is characteristic of Europe as a whole, as well as Japan, and a lot of the East Asian countries.

A cartoon of this which has–a lot right about and one big thing wrong with it, is that here’s the rich countries, they start–this is the pop–rate of increase of population growth, that they start earlier, he starts it quite early in France, and 100 years later–in this graph it’s called ‘poor countries’ start. The peak, the rise is slow, the fall is slow, the rise is fast, the fall is fast, the peak is much lower here. The peak is about 1%. The maximum rate of growth that Europe ever experienced was 1%, whereas, for poor countries, the average was 2.5% and some were up at 3%. So, enormously greater stress on the countries that went through this very, very fast.

Chapter 2. Issues with Mortality and Fertility Change in Developing Countries [00:11:22]

Why did this happen? Why is it so much faster in developing countries? We say that as each country, as it gets into their transition phase later, everything happens faster. It’s quite a robust phenomenon. Every few years, you say, oh man China or some country, Korea, Taiwan, had the fastest decline ever and then a few years later some new countries enter in and their decline is even faster. One of the main reasons is that contraceptives were invented around here. The pill, the diaphragm, kind of all that–well some of them went way back here but the modern method, the really modern methods were all like the pill in around the 1960s.

This is a graph showing that the developing countries are using contraception, so here is contraceptive prevalence, the percent of women and childbearing ages that use contraception, and it ranges from very little, less than 10% to like 70%. The U.S. is in the 60% to 70% range. Notice that the fertility, the total fertility rate, if the country’s not using contraception, very high fertility rate, as they use more and more contraception their fertility rate goes on.

The mechanism in the developing countries is use of contraception and mostly modern contraception. Whereas, when Europe went through its transition, they didn’t have hardly any contraception. Some condoms were just beginning to come in but none of the modern chemical methods or the better kinds of barrier methods. The story is kind of–that, why the developing countries are faster is that the science is already there, the medical stuff is there, the death rate comes down because again Europe developed the medical know how and then it just got transferred very rapidly: vaccines, vitamins, viruses, all of those were discovered before the transition there.

Just as important as the knowledge was an attitude toward civil government and civil society that it is the responsibility of governments to take care of the health of their people. That’s not a given. Most countries, through most of history, the government was rapacious and their idea was to get as much taxes from the peasants as possible. The peasants were sort of like non-humans and use those taxes to have an army and go try to get–enlarge their territories. The idea of civil government, where the government is for the people is a fairly modern idea and one of the basic things that governments try to do is public health.

Then of course–on the technology, the contraceptives I’ve mentioned, the means of mass communication, I’ll show you a slide later that change in behavior is triggered a lot by what you see on television and what you see on [correction: hear on] the radio, what you see in newspapers. As in chimpanzees, we’re a very social species, and we’re always looking to see what’s acceptable, what kind of behavior is acceptable. Gossip, maybe I mentioned this, that most of what humans say to each other is gossip and the function of gossip is to find what are the limits of acceptable behavior, so the mass media is extremely important in like telling people in this case that two children is the proper way of families. They see American television, American movies, or Japanese, and what do they see? Rich people with two children, whereas as they previously believed that in order to be rich in some sense you have to have eight children, so the media are very important in changing perceptions.

Also, for a very long time, maybe not now, the West had–cachet–was considered the future, the modernity, the West was very respected and loved around the world and so the use–the small family norm was a characteristic of the Western, a lot of people tried to become like the West, there was that cachet. Of course family planning programs, the west had a long experience with family planning programs. You’ve read some of the Margaret Sanger stuff from America, the Marie Stopes stuff from England, where people are struggling with these things and finally come out the other end and decide to gain control of their fertility. In a sense, both medically and culturally, Westerners were the guinea pigs for this fertility transition and then once it was, in some sense, perfected and finished in the West, it was sort of transferred wholesale to the newly developing countries.

Now another thing about the fertility transition is that not only is it more intense demographically with all the statistics that we can gather, but it’s also more intense emotionally. As you’re for sure well aware by now in this course, there’s enormously strong social norms about sex and reproduction, and if those norms are about to change it attacks one of the most important foundations of a culture and there’s–that does not happen without a lot of conflict within the culture.

In the West, although there’s a lot of discussion about this, the idea of individualism, that people individually go out and do what’s good for them, they make choices based on their own desires. There’s kind of a long history of that and it was sort of formalized by Adam Smith in economics saying, that if everybody went out and tried to get as rich as possible it would be wonderful for everybody. In most of the developing countries they have a more communal kind of attitude, whereas, often if you speak to older, say Chinese, or Indians–the smallest unit of desire which they speak of is the family; very hard to get them to think of what THEY want. It’s the family, or village, or some larger entity.

When you start changing norms, the norms in non-Western societies or pre-modern western societies are very much stronger in control of the people. People have less latitude to go and do their own thing; they’re under social–much more social control. Of course all of these things multiply–square these things, quadruple them, if you’re talking about sex.

One of the readings, I don’t know if you’re going to do it tonight or you did it already, about the Palestinian woman who was killed. Did you–was that–not in your reading yet. What it is, that a Palestinian woman was suspected of some infidelity, no hard evidence for it, and her little brother killed her after searching for her for many years. The idea of giving you that article is it’s a tear jerker, but it gives you an idea of the emotionality of the–strength with which the older social norms are held and someone who appears on the surface, even mildly, to violate it, can get killed.

A Jordanian woman has just come out with a book 2003, Honor Lost, and she talked about her best friend and this is what triggered her, apparently, to write the book. This woman, her friend, had been seen in public walking with a man who was not a relative. Now not doing anything bad but right there in public, so you know nothing was going on on the streets and this being seen alone–being seen on the streets with a man who was not a relative was such a stain on the family’s honor that the woman’s father stabbed her 12 times in the chest and then stood over the body to make sure that she was dead before calling an ambulance.

Imagine the strength of the cultural norms that allows a brother to kill a sister, or a father to kill his daughter. In this last case, this woman who the father killed her, the family was not poor and was not Muslim, even though it’s in Jordan but they were middle class and Roman Catholic. So that means–almost nobody in these cultures escapes the cultural norms even though Catholics in Jordan are a very small minority as is the middle class in Jordan. They obey the same rules of the culture as everyone else. The author of that book claims that this happens to thousands of women, that there’s thousands of women dying in honor–so called honor killings.

Now, of course, it’s not restricted to the Middle East, you will read a little bit later a reading for India where a woman is raped by her father-in-law and her own father insists on killing her. That’s from India. You have to contrast this with, not all cultures are like this, so contrast this very tight strict norm about women’s–not giving women any possibility for going beyond the norm, compare it with the Na of China which I think you’ve already read, where everything is totally free, or the Japanese, the story of the Suye Mura women; have you read that yet? Again, there’s a huge amount of sexual freedom. So it isn’t that all cultures have the same cultural norms, but they all do have cultural norms and violation of those cultural norms will be punished.

Another thing is that, in the different stream, the Western and Eastern fertility transition, is that the economic constraints, the level of poverty in the third world is much worse than it was in Europe at the time of its transition. Everything is more difficult when you’re poor and you live in a poor country with poorly developed government, everything is more difficult. In your reading packet is a one page collection of headlines from Tanzania and you just see all the problems that Tanzania is going through in a period when their fertility is high and maybe beginning to start falling down.

Chapter 3. Volume of Population Growth in Mortality Transition [00:22:27]

We have some understanding of the many ways in which statistically, except by magnitude, the fertility of the demographic transition in the countries that have entered since 1960 looks very different from those that entered it in 1860. Quantitatively also, when you go through a period of population growth, the question is well how much did your population grow altogether between the beginning of the transition which we’ve had the beginning in Europe and the end in Europe, as your text says something like 1870 to 1930 and Europe grew by about a factor of four, so the population quadrupled. This was the time when the population of the developing countries was staying constant.

But developing countries–India actually, as far as we can predict, is having one of the smallest between four and five, so they’re sort of at the maximum for Europe, no country in Europe was more than four and India, one of the lowest countries for the developing world, would be somewhere between four and five so we expect. Mexico will have grown by a factor of seven to ten times; Kenya by more than fifteen times, so here is again, countries that started the transition poor, they’re still moderately poor, Mexico is doing better but certainly Kenya is not and India is doing somewhat better. And now they have to cope with five, six, seven, eight, nine, ten times as much population.

Because of these multipliers, the fraction of people in the different parts of the world goes first one way and then the other way. Before the mortality transition, Europeans represented about 18% of the world’s population. At its maximum, when Europe had the maximum, Europe and European people in America, Australia, New Zealand and so forth, but European stock people their fraction–the European fraction of the world population doubled, more than doubled actually from–about doubled from 18% to 35% so they–Europe was undergoing–Europeans were undergoing a huge population thing. Now–by 1995 because Europe’s population growth is over, European people’s are over, and the developing countries population growth is starting it’s back to where it started and it’s back to about 18%.

Now–that’s 1995 and we’ve had already 13 years of population growth continuing in the developing countries and it’s continuing and getting more and more. The relative percentage of people in, what’s now called the developing world versus the European world, is going now to be so high in the developing countries that it’s way beyond anything that was historically the case, except maybe when humans started moving out of Africa and into the Middle East and into Europe. This may not stabilize–so far there is no sign that European population, almost all of the European populations now have fertility rates below 2.1 and so they are going–if they continue with that of course they eventually disappear altogether, and the idea that there’s going to be some stabilization at some ratio of say rich and poor countries is dependent on fertility coming up in developed countries and we don’t have any reason to expect that.

This is an important factor because, if part of the developing countries coming out of poverty, is aid from the West and that’s again–everything is debatable in this course, how much help aid does. It actually–there’s no question about that in some cases it’s tremendously helpful. That if there’s nobody left in the developed countries to give the aid, then one of the props which helps developing countries come up will have disappeared.

Chapter 4. Comparing Fertility Transition to Famine [00:26:55]

We’ve gone through the quantities of the transition, but we have compared the demographic transition of developing countries with European countries, but we haven’t compared it to anything else. The world population, as I say, is growing something like 70 to 80 million people a year. The question is, if we imagine some sort of a landing for this, what kinds of things are going to stop this population explosion? There’s bad things and there’s good things; bad possibilities and good possibilities. The bad possibilities and have been known–have been thought about for a long time is 1) famine, that people could start starving, disease, AIDS, people are always talking about Aids balancing the population explosion or war. I’m going to give you some idea of the magnitude of these factors.

Famine, one way that famine operates is, some country has a big drought and they go through a short period of terrible famine, but that’s not the main thing. People all over world and especially children are malnourished and malnourished leads to disease. It’s very hard to get these statistics and to gather these statistics, and it depends on who you’re talking too. I was teaching in a health course and we sort of did serial lectures and Michelle Barry, a professor of international infectious diseases, gave the lecture before mine, so I went to her lecture to see the lay of the land, and she was describing millions of deaths from various diseases.

The medical students, this was to medical students, had no clue and they were just absolutely shocked at the magnitude of what’s going on, especially in developing countries. She was listing, maybe you know, Aids is about–back then it was two million a year, it might be three million and coming down; Malaria, tuberculosis from the one to two million deaths a year kind of thing; diarrhea in children, etc. These are–the massive killers in the world. Next week I came on and said, you know what, there’s x millions of deaths from malnutrition and they were shocked because it was an even bigger number then what Dr. Barry had given.

I said, you know what, they’re the same deaths you heard about last week. The thing is something like–I don’t remember the number, something like if you take a skin test for tuberculosis, something like a third to a half of us have been exposed to the TB bug so that we have antibodies against it. We basically in some sense, in a small sense, have had TB. If you go to India more people have had it but the fraction that actually come down and get sick is much, much higher.

Why? Malnutrition. That all of the diseases, if you’re malnourished your immune system and your other body systems can’t fight the bug, so you actually get sick and will often die. There’s a big discussion of when you see a death to say TB, is that death caused by the tuberculosis bacillus or is that death caused by malnutrition? The World Health Organization and a lot of other groups are now saying that the about half the deaths from all these things are really at base caused by malnutrition, that at the level of infection that the people are exposed to, you should see so many deaths but you actually see twice that many deaths because people are hungry.

The numbers from the Food and Agriculture Organization of the United Nations are–is that 25,000 people die every day, like today, 25,000 people will die from starvation or malnutrition. That’s a huge number. That’s nine million deaths a year and so I calculated it out, during the course of this lecture 1,300 people will die of starvation or malnutrition. It’s really very serious. Most of the death–yeah?

Student: How many people are born during this lecture?

Professor Robert Wyman: What?

Student: How many people will be born during this lecture?

Professor Robert Wyman: Also a very large number, more than the deaths. We’ve seen that the–you can calculate it yourself that the birthrate is something like three times, two and a half times the death rate, but that’s not just that–you can sort of double the total number of deaths will be something a little more than double the deaths from malnutrition, so a lot. The population is still growing I’ll bet, as you’ve seen, because we do have a lot more births than deaths, and I showed you that data before. [The answer is: in 75 minutes about 20,000 babies are born.]

Malnutrition is the leading cause of death in children in developing countries, and the numbers you read are all over the place, and one number that I pulled out is 13 million child deaths a year and I’ve seen lower than that. The World Bank in the–it’s millennium goals, you know the big millennium goal thing what the whole world is supposed to go to, says again, that half the deaths of children under five are due to malnutrition and–there’s altogether, for all reasons, there’s 13 million child deaths a year and you get numbers from different studies saying anywhere between a third and a half of these deaths are due to malnutrition.

What does malnutrition look like? You may have seen–this is kwashiorkor, how many of you have heard of that? It’s a very prevalent kind of thing. Do I have a slide? You go to a village in poor places and you see these distended bellies? This is everywhere and actually we don’t even–in –there’s a tremendously prevalent thing, we don’t actually know the cause of it. The old story was that it’s a protein deficiency disease and protein makes albumin and albumin holds water into the blood and the tissues, and when you can’t hold water, it sort of floods into your tissues and spreads out, but now there’s a lot of other theories and we just don’t know really what’s the basic cause of kwashiorkor. It is malnutrition. That’s–there’s no question about it, but exactly what in the diet is missing is not totally clear.

Here’s another kind of shocking thing, now I’m going to give you some shocking pictures and tearjerkers but it’s important to see. This you’ve seen. This is an American missionary or aid worker, I don’t know which and that’s her baby and that’s this baby and they’re both six months old in Africa.

Another thing that happens is that population–when population grows the people who are strongest take the best land and they push out people that are less strong, or have less population or are less violent or whatever reason, or less technologically advanced, they push them into marginal land like deserts. This is the site in Mali of what used to be one of the largest lakes in Africa and then it goes through periodic climatic things; it dries out every so often. In some sense, people should not be living there because you know it’s going to–it goes every so often through droughts, but they have no choice because stronger people’s in the past have pushed them into these desert kind of regions, one of the results of population explosion.

I’ve told you, in Europe, where the extra farmers had to go up hillsides and into less profitable land, so there they are in this very arid region and in normal years they can survive, but then comes a drought and this kind of thing happens and the result, of course–this is a boy who is I think nine years old or something, he’s 13 pounds and almost impossible to keep that boy alive. Here’s one of the really saddening pictures that–in the political discourse about population, and fertility, and family planning in America there’s a lot about motherhood, how wonderful motherhood is – everything but you have to see–well I didn’t show that. I’ve got–I put in the wrong picture which is maybe good for you.

Now you’ve seen a lot of these pictures. The organizations, they want you to give money show a lot of them and one of the discussion items about these kind of pictures is that they make people in poor countries seem sort of helpless and that’s not true. The amount of stuff that people in these countries are doing to try to help themselves is enormous, they can be very strong and very smart people, but their resources are very limited what they work with.

The bottom line of this little bit is that given the number of deaths that we understand to be from malnutrition and given the number of population increase, if the solution is to be solved by famine, if the balancing of births and deaths is going to be a famine situation, the starvation rate must increase by a factor of eight, plus or minus.

Chapter 5. Comparing Mortality Transition to Disease and War [00:36:57]

The next thing is disease; disease is the second of our triplet of horrible solutions. In 2008 it killed about three million people, up from two million, and this is clearly–apparently the peak. Everyone apparently–Because of the retrovirals and various other public health measures, the number is supposed to go down. The numbers are already changing. At the end of 2007, the UN got a whole bunch of better data from certain countries and they had to–they lowered the number of people they thought to be infected with the AIDS virus by 6.3 million. So something like 33 million people infected with AIDS, and presumably they will all die at some point, although the retrovirals can keep them alive a long time.

Notice that 33 million is less than half of one year’s population growth from AIDS. It’s–the way it works out demographically is here is somewhat older data at the–from the peak of the AIDS epidemic, this is the impact in Sub-Saharan Africa with and without AIDS, so the gray–the purple is the way the population -was modeled to increase without AIDS, as if there was no AIDS, and then with AIDS, AIDS kills these people basically, prevents these births, you still have an enormous population increase for Sub-Saharan Africa which is the worst affected place. This is one of the worst scenarios –they did a worst case scenario run which they sort of imagined things to be about as bad as they could get.

This thing, when you do it for a whole–most of a continent hides a lot of difference; this is Uganda, which had a very intelligent response to AIDS and here, with AIDS there will be this much, and without AIDS there would have been this much, but population keeps growing. In any case, in South Africa, which is about the worst really badly hit place you do see that population growth without AIDS would be this and they’re actually expecting population growth to come down as a result of AIDS. In some countries, it has an important demographic effect, but for Sub-Saharan Africa, as a whole, not an enormous effect.

In the rest of world, where, at least so far, the numbers are much smaller, a minor effect. It can easily get lost in the statistical noise that we don’t know how many people are on earth, we don’t know exactly how fast the population is growing and AIDS can be within that statistical noise.

From a demographic point of view, AIDS as a killer, is significant. Let me show you there’s another thing that kills 1.6 million people more than half of the AIDS number. You’ll never guess what that is? It’s this, it’s smoke from cooking fires, that in the developing countries, in the poor countries, this is the way people cook and the smoke fills the room, gets into their lungs, and they get all kinds of diseases extra and the estimates of that is 1.6 million deaths; comparable to tuberculosis and malaria and somewhat less than AIDS.

They have a solution to this and it’s a stove that keeps–that you don’t get these kind of smoke with. And those cost $10 each and they’ll cut out a number of deaths equivalent to half of the AIDS deaths. One of the things–if you’re interested in understanding the magnitude of the problems of the world, one of the things you just have to pay attention is the magnitude of the problem and the magnitude of any solution. When there’s an almost sure thing of $10 available and retrovirals cost an awful lot more, which kind of person are you going to try to save? The person that can be saved by $10 or the person that needs $1,000 to be saved if you have limited kinds of money.

From a demographic point of view the problem with–almost worse than the total number of deaths because malaria’s been killing people for a long time, and TB and these are all horrible situations, of course every death is a horrible sort of thing, but AIDS kills people in the prime of their life and that’s–this is what we call hollowing out of the Age structure so there’s children who are dependent, there’s adults who work and there’s old people who are dependent. If you kill off your working people that leaves the kids with no one to take care of them, no one to provide economically for them, that leaves the old people with no one to take care of them.

The direct deaths from AIDS itself is one horrible thing, but what they do to taking care of everybody else in the population multiples that effect by a lot, and as of 2001 the last statistics that I could find, there’s about 12 million children that have been orphaned in Africa due to AIDS. That is–we do a lot of work in the political refugees, that’s triple the number of political refugees that there are in Africa.

We’ve done famine, disease, and wars is the last set of numbers and you hear it at cocktail parties that some war, whatever the current war is, will balance births and deaths. The worst we’ve had is the atom bombs, and I don’t know if you know what the numbers on the atom bombs are, but the Hiroshima bomb killed 75,000 people, the Nagasaki bomb killed 25,000 people. That’s 100,000 people dead in two quick flashes. The population on earth grows by approximately 200,000 a day.

What that means is that, if we can imagine, and all these are imaginary, if we imagine that some wars are going to balance births and deaths on earth that means that every day you have to blow up two Nagasaki bombs and two Hiroshima bombs, killing that equivalent number of people just to keep even. That doesn’t reduce population, that just keeps population flat. The idea of giving you all these horrible numbers is just to give you an idea of the magnitude of this issue and that it’s of course absolutely unthinkable that one sort of continues to just let this situation go rampantly until one of these negative kind of disasters happens. There’s got to be a solution. We have to figure it out in some way.

So far in the last lecture or so, I’ve obviously been what we call apocalyptic. The world is coming to an end due to population explosion, but there’s a famous saying to the opposite, which is that if something can’t go on forever, it won’t. I think that has a large chance of happening and I’ve described some of this already to you in our last lecture and I’m going to talk more about it right now.

Chapter 6. Desires to Decrease Fertility [00:44:49]

Consider these two interviews, one is an interview very much like one of the ones in your readings, it’s from Mali in 1983, Sitan. This is a woman who’s heard about the contraceptive pill but has not used it. Interviewer: “Sitan, how many children more would you like to have?”

“That is for God to decide.”

Interviewer: “You yourself, how many more children would you like–how many children would you like to have in your whole life?”

“I don’t know the number. It’s when God stops my births.”

Interviewer: “How many boys and how many girls would you like to have?”

“It’s God that gives me children. Since it is God that gives or not, you cannot make a choice about your children.” You’ve read some of these, this is a different country, a different time, but this is a not uncommon sort of attitude where people, women especially, just can’t–it’s not within their calculus of conscious choice.

Now in Bangladesh, which is again, both of these countries are Muslim, Bangladesh is more conservative religiously. The poverty getting better now, but it was about the same, so there’s the socioeconomic indicators for the two countries are about the same, but the government in Bangladesh was very different and the government, from very early on, decided that they would make family planning available in the country and the international groups then came on board and said, okay, we will help you.

This is now another interview with an 18 year old girl named Shamiran and she is just learning that there is such a thing as birth control. The reason she knows about it is that, and you’ll read about–you’re going to read about the family planning program and the results in Bangladesh, is that as I said Bangladesh is a very conservative Muslim country. So, women generally are not allowed out of the house to get medical service for instance. Just to go out and talk to women’s meetings where these things get discussed. No. They can’t do that.

The family planning program in Bangladesh, the government program and the private program, hired high class women from that community, who themselves were using family planning and thought it was good and sent them into the houses of poor women who couldn’t come out. This is kind of like if Muhammad–the mountain won’t come to Muhammad, Muhammad will go to the mountain. The people in the village all know about this woman who, Mukti Ma, that was her name, and she’s considered a health worker and she actually gave her aunt, her aunt was an acceptor and Mukti Ma was giving–came by regularly to give her aunt pills and the girls knew about it.

But they didn’t really understand it and so they went and asked the aunt, the girl Shamiran, and the aunt refused to tell her anything because again the social conservatism, that these matters will be explained to her only when she is married and she’s not to know anything about this now. What did the kid do? Like every kid everywhere else in the world she goes to school and talks with her friends, and they all pick little bits of information or misinformation and pull it together from the other girls.

Some of them apparently knew of Mukti Ma, some of them didn’t know about her. I’m sorry I said everyone in the village knows, apparently they didn’t, but since this girl’s aunt was getting pills from Mukti Ma she knew about it, but every one of her schoolmates was interested. One girl said, “I would like to work as she does,” she Mukti Ma. “Look at her, she wears her sari so nicely and goes to different neighborhoods. My sister told me she earns a good amount of money.”

Others said, “but my father and grandmother says she’s not a good lady.” Shamiran said, “Grandmothers and fathers are always behind the times, they do not want to let girls go to school, I don’t want to consider their opinions, I like Mukti Ma’s work and I will have pills to control births.”

Some girls said, “Yes, I think we should have this medicine so we will not have so many problems with so many children. With few children, we’ll be able to keep our saris clean and nice,” Then everybody laughed together and that apparently ended that interview.

This is an older generation versus a younger generation and there’s an interest of the girls, as they self perceive it, and the interest of the older generation, as they are trying to impose it on the younger generation. It’s a very clear kind of a conflict situation. The girls see having many children as just causing a lot of problems and what the girls are interested in is not having a lot of children as–which was terribly important to their–certainly their grandparents and probably their parents.

They want to have nice clean saris and look nice. They want to be able to earn money and go around to different neighborhoods. The older generation is trying to keep them out of school, keep this information away from them, and keep them in the mold previously. The girls in that society are pretty much powerless because even though the age at marriage has risen, Shamiran’s already 18, which traditionally is terribly old for a girl to be unmarried. She’ll eventually get married, moved in with her husband, and the husband will also be a teenager probably and will have not much say – the husband’s mother will be the arbiter of medical things, reproductive things, so that both the son and the daughter-in-law will be under the control primarily of the mother-in-law and so it’s the mother-in-law’s opinions that count, the mother-in-law’s attitude toward reproduction that counts.

Very often we, in the west, say that–the problem is all with men, the macho men force women into having children and some of that is certainly true and sometimes in Latin America a fair amount of that can be true, but in Asia it’s very often the mother-in-law. Wherever you see that the young girl–they get married young, the husband and wife are both young, they move into the husband’s house which is the grandparents house, then the boy will be under control of his mother and the new wife will be perhaps almost a slave to that mother. You have many, many instances where both the boy–the husband and the young girl wife do not want to have children but they don’t have any choice. In matters of reproduction it’s mother-in-laws who are the dominant transmitters of culture in the thing–in the world.

I showed you in the data at the beginning of last lecture that the Shamirans of the earth, who are not so enamored of having a lot of children, have taken over from the Sitan’s of the earth, who will have as many as they’re going to have. The data was very strong that women in the developing countries don’t want all the children that they’re currently having.

You’ve seen new data and you’ve seen old data from that. I showed you Bolivia new data you could–I can–you can come up to my office and see the Demographic & Health Surveys and pick a country and it’s pretty much all the same. With the exceptions of Sub-Saharan Africa is somewhat exception and some of the Arab countries, not the Muslim countries, many Muslim countries have really reduced their fertility but Arab countries are going through a non-standard situation.

This information has been–we’ve had this since about the 1960s. We’ve had it for about a half a century, knowledge that women in the developing world don’t really want the children that they’re having. In the 1960s they started with a survey called KAP, knowledge, attitude, practice. Knowledge: did you know about contraception? Attitude: do you want it, what do you think about it? Practice: are you actually using it? Then from 1972 to 1982 there were surveys called The World Fertility Survey which were improved from the KAP surveys and they reached 62 countries with 350,000 women interviewed, and then from 1985 they’ve been coming along with these Demographic & Health Surveys, which are more or less standardized across the world, and from which the data I gave you came.

If you listen to the verbal report of these women, they say they don’t want these children. The question–you have to always question–scientists always question everything, okay they say that, but how much oomph! is behind it? It could be an interviewer comes in, obviously a very modern person, you know that modern people sort of think that the modern way is to have fewer children, so you may very well answer them in that way so you can never be sure of these surveys. You always have to look at what are people actually doing and there are various ways that you can find out if this a real–a desire backed by behavior.

One of the things is well how permanent–of those women that choose some sort of family planning method, how permanent is it? How good is it? It turns out that basically everywhere in the world sterilization is the dominant choice for family planning. In Brazil, for instance, by the late 1980s and their fertility has come down from then, 40% of married women using contraception in fact chose to be sterilized over all the other methods. Now you might think that this was the poorest women who chose this, that they were kind of desperate. Maybe they were influenced by family planning workers to just get it over with, and I’ve heard polemical arguments saying that, Oh, these sterilization things are because that was what was pushed upon them by some family planning program’.

In fact, statistics are very clear that the higher the income level of the woman, the greater likelihood that she was to choose sterilization. One of these–have any of you seen this film about testing the birth control pill in Puerto Rico called La Operacion? It’s sort of a far feminist thing but very–shown very frequently. One of the places that the birth control pill, invented in America, was tested was in Puerto Rico. It shows a lot of people, they’re talking in Spanish, but there’s a narrator speaking in English which most everybody can understand, and the narrator is saying how terrible everything is and that these women weren’t told what was going on.

What you see when the narrator is speaking is an older woman who wasn’t eligible to be a subject in the test, at night climbing into the window at the basement of the hospital to get the birth control pill and the narrator says nothing about that, but they’re showing this to you. Have you seen it? I saw–had sort of a hand up.

In the U.S., among affluent, educated women that nobody is presumably pushing around 13.8 million–women use tubal ligation, a female form of sterilization as their method of birth control and less than that 13.2 million were using the birth control pill. In the United States, like in almost every other country, sterilization is the chosen means. I think that’s one indicator that when people say they want reduced fertility they really mean it.

Chapter 7. Abortion [00:57:11]

Sometimes family planning–contraception is not available and then people can get into very desperate situations. An American maternity nurse went to Lusaka in Zambia and this is the University teaching hospital in Zambia. So, most of these developed countries will have a capital city and they have one high class hospital that’ll usually be attached to a university and that’s demanded by the upper class of that country, the political elite, the economical elite demand good modern medical services, it’ll be one hospital there. You can look at the public health budget for these countries and a very disproportionate amount of it will go to this one hospital.

This University teaching hospital in Lusaka is the high level hospital in Zambia. This nurse went into the maternity ward; she was a maternity nurse, expecting to see a lot of women having children. Instead this is what–this is her report. “Ten women with botched abortions were lying on nine beds. Five others were sprawled on the concrete floors of the hallways. A few more were in the hall–on the floor outside the entrance. There were no blankets or covers. Most wait 12 hours for treatment from a physician. The ‘average’ woman ends up overnight on the floor; she receives no food or water. The women were aborting on the floors or on their way to the single toilet at the end of the long hall; 30% of the patients complete their abortions on the concrete floor with no medical care. All we can do is clean it up.” That’s what the head nurse there said, that all we can do is clean it up.

This is not isolated to this one hospital. You can go anywhere in the underdeveloped world and at least half the beds in maternity wards are taken up with botched abortions. What goes on is, in most of Africa, and a lot of the world, abortion is illegal, so doctors can’t do it, so they go to what they call bush doctors, some very poorly trained midwife or someone who just says they’ll do it, and they have this operation and usually something is put up, a stick or coat hanger or something up the uterus and they try to scrape out the fetus. But, in fact, they often puncture the uterus which allows infection to get into the main body cavity, and then after a few days they’re getting very sick from the infection which is now systemic because it’s inside the body, plus the wound doesn’t heal because of the infection so there’s constant bleeding and they can bleed out.

Huge death rates, we’re going to talk about abortion later and I’ll give you some of these numbers, but huge death rates. Important point for this course is that probably all of these women know of someone else who has died from one of these–shall we call them unprofessional abortions. Yet, when they get pregnant, their desire not to have that extra child is so strong that they will themselves choose to undergo this very, very serious operation with a very high threat of death.

That’s one of the things that the Planned Parent Federation in its international efforts like what you saw is trying to cure. They had one project to go to Kenya to train local private doctors who somewhat escape the law in family planning and abortion services. The local doctors had been turning away abortion clients because they did not know where to refer them, so that means they got some unskilled practitioner. One physician told the project director that he had turned away a young girl only to find her in a hospital a few days later after she had procured an illegal abortion. The girl died. The private doctor said that he had since then lived with a great deal of guilt. He is happy now that he can provide treatment using a very safe procedure. In between that they’ve legalized things to some degree in Kenya.

It’s not only the third world in which this takes place. In Bulgaria, sometime back under the Soviet system, 57% of pregnancies ended in abortion. You’ll hear during the abortion lecture in the United States, there’s one abortion for every three live births, and something like 40 to 50 million abortions worldwide and about half of these are illegal and illegal means very unsafe. A woman dies, it’s about every three minutes from a botched–one of these illegal abortions. I think with these stories and the large numbers that are attached to them, I mean any woman in that situation that has an abortion, she does not want that child and when you say there’s 50 million of them worldwide that means that the demand for control of fertility is very, very high.

You’ll read the Brazilian solution to this which is a modern form of infanticide. I don’t know if you read yet, the Death Without Weeping, it’s in your reading packet where mothers who know that they can’t raise a child just leave the child to die and they say that ‘God can take better care of it then I can’ and they just let the child die.

Chapter 8. Family Planning and Fertility Decline Worldwide [01:03:05]

This is not to say that–So, what has happened in the world is that fertility has come down drastically and I’ve showed you that in previous graphs where the fertility is coming down, and in the peak period in Bolivia during the peak–the number doubled from about 12% to 25% of people using a modern method. Ecuador, 50% of the women are using a modern mechanism. Tunisia, 60% and Iran is one of the really interesting cases.

Iran had this very conservative government and they were against family planning and all this, and then they had the war with Iraq. Iraq invaded, with U.S. help, and huge numbers of people died, including a lot of kids, so afterwards their young people were depleted but once those kids–they recovered a little bit from that, the government realized what was happening and decided on a family planning program. This is an Iranian woman packing condoms. We have this image of places like Iran as being so backwards and conservative and everything, but they have, in fact, now one of the best family planning programs in the world, and the UN a few years ago awarded it their top–best program in the world and their fertility rate is now at replacement level.

Fertility is coming down almost everywhere, with again Sub-Saharan Africa and some of the Arab countries as a counter example. Birth rates not only–Birth rates fell; Thailand 50% in 12 years; Columbia 40% in 14 years, this is at the peak. Indonesia 48% in 20 years; Morocco 31% in 12 years; Turkey 21% in ten years; Brazil 60% in 25 years; Mexico 30% in just six years; Botswana 26%; Zimbabwe 18%; Kenya 35%, I mean everywhere that you look the actual fertility is coming down, so people are using contraception and using it efficiently and the world birth rate has come down quite significantly.

None of this is to minimize that people in developing countries are caught in a bind, that you all have heard all kinds of reasons why they might want to have a lot of children and one is extra farm labor. One is support for children in old age, a major kind of problem. One their religion might demand it. Two cultural reasons, various ancestor worship reasons. In India you have to have a son to light the funeral pyre, no son you don’t go into the afterworld properly. We discussed some of this with respect to Africa. Status reasons, you have more children you have more prestige for both the man and the woman, there’s macho reasons to prove your fertility and the list goes on and on.

The reasons they may not use birth control are many, one of which is family planning services can be very primitive. It’s not a great slide but it’s an old bus in India with a red cross on it and this is the family planning clinic in this part of India at that time. People were supposed to go on this bus and have some operation that they didn’t understand done to them, sterilization or IUD insertion or something, and you know you wouldn’t be exactly very anxious to get on to that bus.

Another thing that I mentioned last time with respect to Veena’s lecture, that the worry about medical complications is one of the most major reasons why women either don’t use contraception at all, or start it and then stop using it. What does this mean in a pre-medical country where they don’t have really modern medical ideas. You take the pill, you’re scared of it. Anything that happens to you, you get a tummy ache, you fall and break your leg, anything that happens to you what do you blame? You blame the pill. So here is a culture without much medicine, a low standard of living; they’re getting sick a lot. People in developing countries are not generally very healthy and they get sick and they don’t know what it was caused by.

You probably read already about The Evil Eye. Did you read the Egyptian–the Kul Khaal yet? The Evil Eye is the reason. If you’ve taken the pill you know that’s changing your body in some way, and you’re afraid of it, you get sick with anything, it’s the pill was the reason for it and then you tell all your friends that and everybody in the community learns that such and such got some problem because of the pill so they’re very much afraid to use the pill.

On an on, there’s a big conflict, big contestation, the media, I think this is in Morocco, this is a cave, this is the desert around here, they’re in a cave and what they’re watching is a TV show. I was in Morocco in the far desert and you see these little villages of just a few mud houses and they all had solar arrays and they all had television, so media is passing on very strongly. On the other side of the equation is all kinds of reasons that they don’t use it or that they do use it. It’s a very much in contestation.

In the West, especially activists, liberal people, people in the Forestry School believe that we shouldn’t support family planning programs because it’s politically contentious. Why is it politically contentious? Because people on the right are opposed to it for religious or moral reasons, people on the more or less left, and these are characterizations right and left. We can’t impose; we ‘great white Westerners’ can’t impose our values on our ‘poor little yellow and brown cousins’. It’s utter nonsense and it’s patronizing because the people in these developing countries have spoken very clearly when they add up all these pluses and minuses. That’s their choice, and as I’ve showed data–I’ve hit you over the head with data showing you that when people in the developing countries themselves add up the data, they want to be protected by contraception.

I think that we, in the West, ought to take that very seriously, and starting with intellectuals who should know better, but since people don’t give courses like this and people–even environmentalists and all kinds of others, just don’t pay any attention to human population because it’s politically untouchable. The major organizations, the environmental organizations won’t touch it because they do fundraising and the public opinion is that–it’s a horrible thing to push family planning on developing countries. I guess that is where we will end today. See you–yes one more this week before vacation.

[end of transcript]

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