Harvard Center for Population and Development Studies

2. Harvard Center for Population and Development Studies Dedicated to understanding the dynamic interplay between population health and the social and physical environment Lisa F. Berkman, Ph.D. Director Thomas Cabot Chair of Public Policy, Epidemiology and Global Population Health

3. Global population health and well-being are both determinants and consequences of major demographic changes Migration within and across countries Women in the paid workforce Decreases in fertility and increase in life expectancy in many countries

4. A 2007 volume on environmental conditions and population showed this incredible photo on their front page.. Living in two worlds, people in Cairo will confront traditional ways of travel and live in both old and new worlds simultaneously. How will they do it?A 2007 volume on environmental conditions and population showed this incredible photo on their front page.. Living in two worlds, people in Cairo will confront traditional ways of travel and live in both old and new worlds simultaneously. How will they do it?

5. So, what�s the world going to look like in the next 20-40 years�by 2025 or 2050? Increasingly urban Increasingly old Increasingly diverse with migration Increasing women in workforce And in the coming decades what will the world look like� in many ways we don�t know but we can say now, it will be increasingly urban, old, divers and include women in the paid workforce in ways that past generations never experienced. In the next slides, Im going to show you first the FACTS as we know them now, secondly the consequences of demograhic transitions for how families and communities and nations may face and third, Ill show some ways in which social and economic policies may offer successful strategies to ensure that these demographic transitions yield the kinds of fruit?) we want to improve well being world wide. In the end, demography is NOT destiny, rather it is how we confront it and solve the challenges we confront that is critical.And in the coming decades what will the world look like� in many ways we don�t know but we can say now, it will be increasingly urban, old, divers and include women in the paid workforce in ways that past generations never experienced. In the next slides, Im going to show you first the FACTS as we know them now, secondly the consequences of demograhic transitions for how families and communities and nations may face and third, Ill show some ways in which social and economic policies may offer successful strategies to ensure that these demographic transitions yield the kinds of fruit?) we want to improve well being world wide. In the end, demography is NOT destiny, rather it is how we confront it and solve the challenges we confront that is critical.

6. FACTS: Growing diversity: often within very large cities While the worlds urban population grew very rapidly over the 20th century ( from 220 million to 2.8 billion) the few decades will see growth on an unprecedented scale. Between now and 2030, town and cities of the developing world will make up 81% of the urban humanity. The enormous scale and impact of future urbanization has not penetrated the public�s mind.While the worlds urban population grew very rapidly over the 20th century ( from 220 million to 2.8 billion) the few decades will see growth on an unprecedented scale. Between now and 2030, town and cities of the developing world will make up 81% of the urban humanity. The enormous scale and impact of future urbanization has not penetrated the public�s mind.

7. Global Urbanization:1975-2025(2007 - 49%, 2025 - 57%, 2050 - 70%) Ten largest cities 1975 Tokyo New York Mexico City Osaka Sao Paulo Los Angeles Buenos Aires Paris Calcutta Moscow Ten largest cities 2025 Tokyo Mumbai Delhi Dhaka Sao Paulo Mexico City New York ( Newark) Calcutta Shanghai Karachi in 1975 here are the worlds ten largest cities- in countries like japan, mexico, Brazil, France, India and Russia By 2025, here are the worlds tens largest cities: they are in Japan, India, Brazil, Mexioc, China, Us and Bangladesh. Most countries invited today. Cities concentrate poverty__ but they also represent the best hope for escaping it. Cities embody the environmental damage done by modern civilization� yet if they create problems, they most contain solutions. in 1975 here are the worlds ten largest cities- in countries like japan, mexico, Brazil, France, India and Russia By 2025, here are the worlds tens largest cities: they are in Japan, India, Brazil, Mexioc, China, Us and Bangladesh. Most countries invited today. Cities concentrate poverty__ but they also represent the best hope for escaping it. Cities embody the environmental damage done by modern civilization� yet if they create problems, they most contain solutions.

8. FACTS: Aging societies will be worldwide

9. Global trends in longevity This is of course not true everywhere. In subsaharan africa, LE has not changed at all, and in the former soviet countries and much of east Europe, countries are actually fairing slightly worse.This is of course not true everywhere. In subsaharan africa, LE has not changed at all, and in the former soviet countries and much of east Europe, countries are actually fairing slightly worse.

10. Global Declines in Fertility One of the most amazing phenomen, never predicted by the folks who believed in the Population bomb, is the decline in fertility across so many countries. This in part is the result of continued efforts to bring reproductive rights to so many women across the globe.. But there is another part, we understand much less about� which is the huge decline in so many countries, well below replace level. In Places like Japan, many EU countries, much of Eastern Europe, women are choosing not to have children or to have them ( or one to be clearer) at much later ages. Why? Is it work, pessimism about the world,poverty, selfishness, or real engagement� we don�t know much. But demographers, never predicted this set of declines. By XXXX, in many countries in the EU, for the first time, % of adults will not have children. Who will take care of them? How will societies deal with this?One of the most amazing phenomen, never predicted by the folks who believed in the Population bomb, is the decline in fertility across so many countries. This in part is the result of continued efforts to bring reproductive rights to so many women across the globe.. But there is another part, we understand much less about� which is the huge decline in so many countries, well below replace level. In Places like Japan, many EU countries, much of Eastern Europe, women are choosing not to have children or to have them ( or one to be clearer) at much later ages. Why? Is it work, pessimism about the world,poverty, selfishness, or real engagement� we don�t know much. But demographers, never predicted this set of declines. By XXXX, in many countries in the EU, for the first time, % of adults will not have children. Who will take care of them? How will societies deal with this?

11. Total Fertility rate in India, 1977-199 Again, just to show you the spectrum in fertility changes, In India rates have declined but from 4-5 children to just over 3 between the mid 70-s and 1999Again, just to show you the spectrum in fertility changes, In India rates have declined but from 4-5 children to just over 3 between the mid 70-s and 1999

12. Fertility Rate in African Nations And much of Africa still has very how fertility rates. Uganda more than almost any country with between 6-7 childrenAnd much of Africa still has very how fertility rates. Uganda more than almost any country with between 6-7 children

13. Population in Developed vs. Developing Countries by Age and Sex (1960, 2000, 2040) Not only do people live longer , but coupled with changes in fertility ( which we discuss in a moment) the shape of our society changes from what we used to call the classical pyramid, seen here in the top figure to the more rectangular shape we see in 2000, and even more rectagular in 2040. I want you to note that the deeply colored shapes in the middle of the figure are developed countries, but you even see the patterns in developing countries by 2040.. Not only do people live longer , but coupled with changes in fertility ( which we discuss in a moment) the shape of our society changes from what we used to call the classical pyramid, seen here in the top figure to the more rectangular shape we see in 2000, and even more rectagular in 2040. I want you to note that the deeply colored shapes in the middle of the figure are developed countries, but you even see the patterns in developing countries by 2040..

14. FACTS: Women throughout the world work, even when they have young children You can tell the condition of a nation by looking at the status of its women.- Jawaharlal Nehru Women of course have always worked, but now increasingly we see they are in the paid work force. This is true world wide although in many countries, India for instance, it is very difficult to document the extent to which women work for pay ( vs the informal sector). Women of course have always worked, but now increasingly we see they are in the paid work force. This is true world wide although in many countries, India for instance, it is very difficult to document the extent to which women work for pay ( vs the informal sector).

15. Demographic Trends in U.S.: Women in Labor Force with Young Children, 1940-2000 IN THE 1950S ONLY 16% OF MARRIED WOMEN WORKED , MIND YOU 46% OF SINGLE WOMEN WERE WORKING. THE VISION THAT MARRIED WOMEN WERE NOT REALLY IN THE LABOR FORCES AND WE DIDN�T NEED TO SHAPE WORKPLACE POLICIES FOR THEM CONTINUES TODAY DESPIECT THAT FACT THAT THERE ARE ENORMOUS POLICY CHANGES IN MANY EUROPEAN COUNTRIES ( THAT RANK AHEAD OF US IN MANY HEALTH OUTCOMES, ESPECIALLY FOR WOMEN). TODAY 79% OF WOMEN WITH CHILDREN 6-17 ARE IN THE WORKFORCE. THAT IS WHY DEALING WITH PARENTAL LEAVE FOR BIRTH IS HELFUL BUT NOT SUFFICIENT.IN THE 1950S ONLY 16% OF MARRIED WOMEN WORKED , MIND YOU 46% OF SINGLE WOMEN WERE WORKING. THE VISION THAT MARRIED WOMEN WERE NOT REALLY IN THE LABOR FORCES AND WE DIDN�T NEED TO SHAPE WORKPLACE POLICIES FOR THEM CONTINUES TODAY DESPIECT THAT FACT THAT THERE ARE ENORMOUS POLICY CHANGES IN MANY EUROPEAN COUNTRIES ( THAT RANK AHEAD OF US IN MANY HEALTH OUTCOMES, ESPECIALLY FOR WOMEN). TODAY 79% OF WOMEN WITH CHILDREN 6-17 ARE IN THE WORKFORCE. THAT IS WHY DEALING WITH PARENTAL LEAVE FOR BIRTH IS HELFUL BUT NOT SUFFICIENT.

16. Warning: extrapolating the future from present trends can be dangerous People change behavior based on predictions zero population growth may actually happen

17. A few months ago a really intriguing article appeared in nature�which captured the headlines int eh economist- so you know its important. The authors showed some very recent and new trends in fertility by level of human development and low and behold in relatively rich and well off countries� which had been experiencing declines in fertility, there was an upswing. Here you see in 1975, ferility was dropping with no end in sight.. In 2005, you see this uptick to just two. Again, not in all countries as the next slide shows�A few months ago a really intriguing article appeared in nature�which captured the headlines int eh economist- so you know its important. The authors showed some very recent and new trends in fertility by level of human development and low and behold in relatively rich and well off countries� which had been experiencing declines in fertility, there was an upswing. Here you see in 1975, ferility was dropping with no end in sight.. In 2005, you see this uptick to just two. Again, not in all countries as the next slide shows�

18. Japan and canada continue to drop but in the far right quadrant you see countries literally splatter across the graph..Japan and canada continue to drop but in the far right quadrant you see countries literally splatter across the graph..

19. CONSEQUENCES: What are the consequences of such demographic and health transitions for societies across the world? Worst case and best case scenarios?Worst case and best case scenarios?

20. Young Children and Older People as Percentage of Global Population (1950 to 2050) Does this mean we need to allocate more resources to the elderly or- just the opposite� we had better attend to young people because they are the future.. Of course ALL the 65 years in 2050 are already born ( 1985) and are now 25� look around� are we doing well by them. Will they be resilient 65 year olds or frail and more challenged than our current 65 years olds? Does this mean we need to allocate more resources to the elderly or- just the opposite� we had better attend to young people because they are the future.. Of course ALL the 65 years in 2050 are already born ( 1985) and are now 25� look around� are we doing well by them. Will they be resilient 65 year olds or frail and more challenged than our current 65 years olds?

21. China�s Declining Ratio of Covered Workers to Pensioners (1980 to 2005) This slide shows the ratio of workers to pensionners in China. The ratio in 1980 was about 55 workers to one pensionner, by 2005 its 2 to 1. Is this sustainable?This slide shows the ratio of workers to pensionners in China. The ratio in 1980 was about 55 workers to one pensionner, by 2005 its 2 to 1. Is this sustainable?

22. Living Arrangements for People Aged 65 and Over in Japan (1960 to 2010) In 1960, 87% of older men and women lived with their children, another 7% with their spouse, By 2010, the number of older people living with children dropped in half to 42%, many more lived with their spouses, but not now fully 18% lived along or in institutions. What will 2020 bring? And how will Japanese society deal with this change?In 1960, 87% of older men and women lived with their children, another 7% with their spouse, By 2010, the number of older people living with children dropped in half to 42%, many more lived with their spouses, but not now fully 18% lived along or in institutions. What will 2020 bring? And how will Japanese society deal with this change?

23. Fragile Families may serve to increase inequality over the coming decades.

24. Child Poverty and Family Structure in the United States (1980-2007) In the US, poverty and family composition are tightly linked ( this is not always true outside the US). Single parents, most often women, often live in poverty, meaning that their children also live in poverty. In 2007, 9% children in two parent families lived in poverty 43% of children in female-householder families If single parents have increased fertility in coming years, inequality may increase substantially. Important to note that single parenthood is NOT the same in the US and is is in EU where most families in fact have two parents, adults are just not legally married. In the US, poverty and family composition are tightly linked ( this is not always true outside the US). Single parents, most often women, often live in poverty, meaning that their children also live in poverty. In 2007, 9% children in two parent families lived in poverty 43% of children in female-householder families If single parents have increased fertility in coming years, inequality may increase substantially. Important to note that single parenthood is NOT the same in the US and is is in EU where most families in fact have two parents, adults are just not legally married.

25. The Health Impact of Work-Family Demands Among Low-wage Workers  Berkman et al. J of Occupational and Health Psychology, in press. In the last several years, we have become very interested in how work and labor policies and more informal practices might influence the health, especially of low wage workers. In the study, we just completed, we interviewed low wage workers in the long term care industry and their direct managers. We measured the openess and creativity towards solving issues of work family needs among employees who mid level managers supervised and then linked it to the cardiovascular health and sleep quality of of the employees they supervise. In the last several years, we have become very interested in how work and labor policies and more informal practices might influence the health, especially of low wage workers. In the study, we just completed, we interviewed low wage workers in the long term care industry and their direct managers. We measured the openess and creativity towards solving issues of work family needs among employees who mid level managers supervised and then linked it to the cardiovascular health and sleep quality of of the employees they supervise.

26. Manager W-F Score and Odds of CHD risk >=2 This slide shows the association between managers score of work family openess and creativity practices and CHD risk. We measured blood pressure, diabetes risk, obesity, cholesterol, and tobacco consumption. Here we see that employees who are supervised by managers who score poorly on implementing work family balance practices have TWICE the CHD risk as those who have managers who are more open and creative in this regard.This slide shows the association between managers score of work family openess and creativity practices and CHD risk. We measured blood pressure, diabetes risk, obesity, cholesterol, and tobacco consumption. Here we see that employees who are supervised by managers who score poorly on implementing work family balance practices have TWICE the CHD risk as those who have managers who are more open and creative in this regard.

27. Manager W-F Score and Sleep Duration Equally striking is the link to sleep duration. Here we see the the relationship between manager�s score and sleep disruption in the employees they supervise. working for a boss who is not �work family friendly� is associated with 30 minutes less sleep per night. We are now involved in intervention studies to see if we can change the work environment and improve both employee health as well as company health by reducing turn over and absenteeism.Equally striking is the link to sleep duration. Here we see the the relationship between manager�s score and sleep disruption in the employees they supervise. working for a boss who is not �work family friendly� is associated with 30 minutes less sleep per night. We are now involved in intervention studies to see if we can change the work environment and improve both employee health as well as company health by reducing turn over and absenteeism.

28. Doomsday scenarios Rising inequality Fragile families and communities New urban areas that can�t catch up quickly Environmental consequences Social exclusion and �dis- integration� Increased conflict So after all this, we might make a number of pretty dismal predictions�So after all this, we might make a number of pretty dismal predictions�

29. POLICIES AND PRACTICESWhat are the policies that nations can implement to ensure population health and well being across social and economic groups?

30. Who Receives Sick Leave? In the nytimes there was a picture of food service workers coming to work, sometimes with H1N1, because they lacked sick leave. The NYTimes showed data revealing that only 22% of the lowest wage earners have any sick leave� no wonder they come in sick� and have sick children going to school.. Among the top 10% of wage earners in the US, 88% have sick leave, with a solid gradient in sick leave related to wages.In the nytimes there was a picture of food service workers coming to work, sometimes with H1N1, because they lacked sick leave. The NYTimes showed data revealing that only 22% of the lowest wage earners have any sick leave� no wonder they come in sick� and have sick children going to school.. Among the top 10% of wage earners in the US, 88% have sick leave, with a solid gradient in sick leave related to wages.

31. South African Old age Pension Program: intergenerational cross-overs In the 1990�s benefits and coverage of the SA social pension program were expanded to the black population In 1993, benefits were about twice the median income per capita in rural areas Pensions received by older women improved the weight and height of granddaughters Duflo. NBER working paper 8061

32. Principles for sound policy Intergenerational and multigenerational emphasis Implement for long-range with lots of planning Gauge the interface between a strong scientific evidence base and political will. Intersectoral action for health and health equity Incorporating a life course perspective on health IM a member of a Macarthur Network on Aging societies and the goals of the network are to understand the conditions that will create successful aging societies--- NOT JUST FOR OLD PEOPLE< but for everyone.. There are a set of principles that we are developing that will guide sound policy creation.. That effective policies will often ( not exclusively but often) have an intergenerational and multigenerational focus� for instance they will focus on family policy or housing policy� not just for old people or kids� but will be conscious of spillovers and cross overs The most effective policies have been implemented for the long range� think of changes in the age eligibility for social security in the US which changed from 65 to 67� that policy was decided over a decade before so people could plan appropriately.. Its has worked without a backlash IM a member of a Macarthur Network on Aging societies and the goals of the network are to understand the conditions that will create successful aging societies--- NOT JUST FOR OLD PEOPLE< but for everyone.. There are a set of principles that we are developing that will guide sound policy creation.. That effective policies will often ( not exclusively but often) have an intergenerational and multigenerational focus� for instance they will focus on family policy or housing policy� not just for old people or kids� but will be conscious of spillovers and cross overs The most effective policies have been implemented for the long range� think of changes in the age eligibility for social security in the US which changed from 65 to 67� that policy was decided over a decade before so people could plan appropriately.. Its has worked without a backlash

33. Goals of Conference Move from the science base to policy Countries learn implementation,evaluation and surveillance practices from each other Learn about different evaluation approaches Create critical mass about social determinants to communicate broadly about social determinants of health- improve political will

34. Demography is not destiny-it is our societal response to it that shapes population health and well-being. We look forward to hearing from our next set of speakers and then will turn to you to find solutions to the challenges the entire world faces� Again, demography is not destiny. Its is our societal response to it that shapes population health and wellbeing. We have an ambitious goal.. We thank you for joining with us today. We look forward to hearing from our next set of speakers and then will turn to you to find solutions to the challenges the entire world faces� Again, demography is not destiny. Its is our societal response to it that shapes population health and wellbeing. We have an ambitious goal.. We thank you for joining with us today.