Population, health, and the environment

1. Population, health, and the environment Stephen Gloyd Problems in International Health HServ/Epi 531 October 2007

2. History of approaches to population Encouragement of population growth Malthus 1798 � anti-public assistance for poor Eugenics movement (USA � 1900-30) Population crisis 1960-80 Debates about population-health-poverty-environment Mexico city conference Cairo conference Clinton-Gore policies (Homer-Dixon, Kaplan) Projections of late 2002 Bush policies (�global gag rule�)

4. Population and poverty & hunger India has 2x more cropped land/person than China Bangladesh has 2x more farmland/person than Sri Lanka Honduras has more farmland than Costa Rica Population density is same in Cuba and Mexico Population and Pollution Average American consumes 30x more than average African African growth rate would have to be 10x higher to be a problem for world�s non-renewable resources Brazil: 2% own 60% of arable land. Logging and cattle ranching patterns reflect land ownership patterns

5. Is population a root cause of� Poverty? Poor families have more children Poor countries have high growth rates Hunger? Famines in India, Bangladesh, Ethiopia World production of food vs population Environmental degradation? Contributors: Rich areas (fossil fuels, consumption, waste) Poor areas (wood (fuel) � erosion)

6. Empirical evidence exists that: Population is growing rapidly (esp developing countries) Migration to urban areas has increased everywhere Poor countries have higher population growth rates Poor families have more children Global environment is compromised by pollution & warming Questions for policy: Are population growth, large family size, high population density root causes of poverty, hunger, pollution? Is urbanization a root cause of poverty hunger, pollution? Does family planning reduce population growth? Does family planning improve health and development?

7. Population Terms Crude Birth Rate # births/1000pop (or women) (General) Fertility Rate # births/15-44 women Total Fertility Rate avg # kids/woman in lifetime Population Growth Rate CBR-CMR Dependency Rate Pop <20 + Pop >65/pop 20-64

14. Population Density ~1997(among countries over 20m pop) Poorest pop/km2 Ethiopia 34 Bangladesh 688 Zaire 13 Burma 53 Tanzania 22

17. Population Density, 2002(among countries represented in the course

18. Is rapid population growth a cause of poverty, poor health? �or, does "slower growth of population foster development? (PRB 99) �Of the large numbers of such studies that have attempted to examine the relationship between population growth and growth of per capital income, some conclude that there is a positive, some that there is a negative, and some that there is no relationship. In all cases, the effects are small; some are, and some are not, statistically significant." Robert Cassen, Pop and Devt, ODC. 1994 General considerations: Increases poverty if % of poor does not change and if social spending does not increase proportional to population growth (obvious, but not prescriptive) Many countries have required additional population (labor force and markets) to industrialize Literature review in 1987: No evidence of causal effect of population growth on distribution of income (in spite of common assertions) (Lam, PopGrthEEconDev)

19. Some specific studies on population growth past population growth = higher GNP/capita growth; recent pop growth = lower GNP/capita growth difficult to assess cause and effect (Johnson,Lee, Pop Growth&Devt 1987) Regression analysis of 22 countries from 1960-1985: Pop growth was not associated with changes in poverty, using different measures of poverty, models, and time periods (Squire, AmEcRev 1993) No evidence of wage decrease during 60-80 population growth (accomodations �land reform, land inputs, increased non-agricultural employment, development of human capital of poor) -prospects for future in Africa are problematic: poor agricultural investment, poor markets) common property decrease from 1950-80 (firewood, free ranging for animals, water, building materials) � but result of government policy as much as growth (Jodha 1990) Decrease educational expense per child in countries with larger population growth � but mostly related to economic adjustment and social policies (Cox, Jiminez)

20. Thus, Causal effect of rapid population growth and poverty is basically unclear �It is likely that �these studies are too unreliable for significant inferences to be made, except perhaps for two: 1) that population is not a dominant effect��.and 2) that no analyses have yet been conducted that fully meet contemporary econometric standards.� Robert Cassen, 1994, ODC Policy Implication: ��If family planning programs are driven by demographic goals (as they frequently have been), they will often fail to address women's reproductive health problems and actually diminish the prospects of the demographic goals being met.�

21. Is large family sizea causal factor in poverty? Theoretical arguments, pro and con: Large family size can lead to poverty by increasing intra-household inequality, by decreasing the ability of women to work for pay decreasing opportunities for education and health of children by reducing the family's ability to save and invest to protect itself from unexpected decreases in income. Large family size can operate to reduce poverty by providing resources to a resource-poor household (from family chores to income generation) providing security for old age enlarging the pool of potential generators of wealth for families who have income insecurity.

22. Why do poor families have many children? Children as resources: labor, income, insecurity Powerlessness of women, men Son preference Religion, social class, culture Lack of health services

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

25. Is High fertility a causal factor in poverty or poor health? TFR and number of sibs not always related (Mali TFR 6.9, sibs 3.4; DR TFR 3.4, sibs 3.7) same Pop Growth Rate Poverty and TFR: Columbia-25% poor, Indonesia-17% poor, TFR same 3.0) Spacing of births and possibly number of sibs is much more important (Ahlburg 94) Summary: �On the whole, it seems that a large number of children in a family has negative effects on the education (and health ?) of children, but these seem to be quantitatively small; moreover, some studies show a positive impact, and some show no impact.� Alhgren 1994

26. Summary Are there causal relationships between: High population growth Large family size High population density and health and poverty indices? Overall answer: Variable associations (positive and negative) Usually small quantitative relationships, if any Not a dominant effect

27. Does birth spacing improve health? Birth spacing (>2 yrs) (estimates from PRB, studies not documented) Reduces mortality of second child by 2x Can prevent 25% of infant deaths Can prevent 25% of maternal deaths (20% if meeting just existing demand) BUT, no change in risk of death Doubling birth intervals increases birth weight 3-6%; postponing birth one year increases BW 1.4-3.2%

29. Does family planning (in general) work? Among users compared to non-users Reduction in child mortality (~25%) Reduction in maternal deaths (~25%) How? Reduces maternal depletion Reduces teen childbearing Reduces abortions (20 m/yr resulting in ~75,000 deaths) Condom use prevents HIV/AIDS Gives women (and men) power to choose when to be pregnant

30. Application of Family Planning programs Large unmet need (Mozambique � 80% want to �rest� between pregnancies) Current demand 150 million women �worldwide Low cost (~$2/cap/yr) Works within health care system Donors like it

33. Myths regarding hunger (1) from �Food First� There is simply not enough food Droughts and other natural conditions beyond human control cause famine There are too many mouths to feed Pressure to feed the world is destroying the environment The green revolution is the answer Efficient production requires large scale farming

34. Myths regarding hunger (2) A free market will alleviate hunger Free international trade would increase exports of poor countries to allow importation of goods to alleviate hunger The poor are too hungry, too passive to revolt against the conditions which make them poor and hungry More international assistance will help the hungry People in rich countries benefit from the conditions which create poverty and hunger in poor countries Societies which have eliminated hunger also eliminate freedoms

38. Does high population density cause poverty? Not necessarily Contradictory examples exist Food supply is not a problem yet What are the consequences of RAPID population growth? Variable Both advantages and drawbacks exist. Population growth and economic growth are not necessarily linked If population grows without economic growth, GNP/capita will decrease; however, this does not necessarily have implications for family welfare Can cause imbalance between capital and labor if investment is poor Hiring more carpenters doesn�t build more houses without tools Labor has traditionally been a positive factor in development Can cause an increase in investment by families Does population growth contribute to environmental degradation? Yes, but the condition of the population is more critical Rich countries with low population growth and low population density are the principal contributors to environmental degradation, not poor countries (USA 5% of world�s population uses 40% of energy) Poor countries often cannot afford adequate conservation policies

39. Do population control programs reduce birth rates? Sometimes Has occurred in Thailand, Cambodia, China Little overall impact has been seen in India (1970s programs) Reduction in birth rates usually occurs with urban migration improved education (and power) of women Is family planning useful? Yes! Spacing of births reduces child mortality, maternal depletion Prevents many abortions Prevent STD Do health programs cause more population growth? It depends. If death rates fall as a result of health care (not well proven), then population growth will occur until birth rates fall (the demographic transition). Other SES factors are probably more important. The length of the demographic transition will determine the amount of population growth. Is population control or growth the best policy? Neither. Equity oriented policies are more likely to improve general welfare and decrease fertility with or without economic growth