Deadly Cities? Spatial Inequalities in Mortality in sub‐Saharan Africa

We investigate whether sub‐Saharan African countries are affected by an “urban mortality penalty” repeating the history of industrialized countries during the nineteenth century. We analyze Demographic and Health Surveys from several sub‐Saharan African countries for differences in child and adult mortality between rural and urban areas. For the first decade of the 2000s, our findings indicate that child mortality is higher in rural than in urban areas for all countries. On average, child mortality rates are 13.6 percent in rural areas and 10.8 percent in urban areas. In contrast, average urban adult mortality rates (14.1 percent) have exceeded rural adult mortality rates (12.4 percent). Child mortality rates are on average 65 percent higher in urban slums than in formal settlements. Child mortality rates in slum areas are, however, still lower than or equal to those in rural areas for most countries in our sample.     

Effects of Childhood Mortality and Morbidity on the Fertility Transition in sub‐Saharan Africa

Child mortality rates have fallen substantially in developing countries since 1960. The expected fertility decline has followed only weakly in sub‐Saharan Africa compared to other recent and historic demographic transitions. Disease and anthropometric data suggest that morbidity remains prevalent in Africa despite child survival improvements. The uniquely high infectious disease burden among children in Africa reduces population health and diminishes the returns to human capital investment, thwarting the quantity–quality tradeoff for children that typically accompanies the mortality transition. Individual‐level data from the Demographic and Health Surveys are used to show that persistent morbidity has weakened the positive relationship between child mortality and total fertility rates throughout the region, slowing Africa's demographic transition.     

The Impact of HIV/AIDS on Adult Mortality in Zimbabwe

In June 2000, an estimated 25 percent of adults in Zimbabwe were living with HIV/AIDS. Statistical data on the impact of the epidemic, though problematic in many ways, are better for Zimbabwe than for many other countries in sub‐Saharan Africa. This analysis presents estimates of adult mortality in Zimbabwe based on multiple sources, including registered deaths adjusted for incomplete reporting, estimated at approximately 50 percent. Comparison of estimates from different data sources shows that they are subject to substantial errors. At the same time, the estimates leave no doubt that adult mortality risks in Zimbabwe more than doubled between 1982 and 1997. The evidence that this rise is due to AIDS deaths is circumstantial, but very strong; there is no credible competing explanation.     

The Trend in International Health Inequality

Estimates of average life expectancy for 169 countries are used to compute the trend in between‐country health inequality from 1980 to 2000. Results show that inequality in the distribution of life expectancy across countries declined in the 1980s, but then increased through the 1990s. The recent turnaround in between‐country health inequality is significant because it reverses a long‐term trend of declining inequality across countries that began in the first half of the twentieth century. The primary cause of rising inequality across countries is declining life expectancy in sub‐Saharan Africa, largely owing to HIV/AIDS. Life expectancy in sub‐Saharan Africa holds the key to the future trend in between‐country inequality.     

Divorce in sub‐Saharan Africa: Are Unions Becoming Less Stable?

Divorce is one of the main drivers of family instability in sub‐Saharan Africa. Using data from 101 Demographic and Health Surveys and novel estimation techniques, we 1) provide the first systematic estimates of divorce across 33 countries; 2) assess trends in divorce in 20 countries; and 3) investigate the key country‐level correlates of divorce both across and within countries. Despite considerable geographic variation, our estimates show that divorce is common in most countries. Contrary to expectations, however, we find no evidence that divorce is increasing. Instead, divorce has been either stable or declining in recent decades. We show that socioeconomic factors associated with industrialization have countervailing effects on divorce. Urbanization and female employment are associated with higher levels of divorce, while age at first marriage and female education correspond to lower rates. These findings have implications for current and future family dynamics in sub‐Saharan Africa.     

Has the HIV Epidemic Peaked?

This study reviews the highly diverse regional and country patterns of HIV epidemics and discusses possible causes of the geographic variation in epidemic sizes. Past trends and projections of the epidemics are presented and the peak years of epidemics are estimated. The potential future impact of new prevention technologies is briefly assessed. A final section summarizes the future impact of the epidemic on key demographic variables. The main finding of this analysis is that the HIV epidemic reached a major turning point over the past decade. The peak years of HIV incidence rates are past for all regions, and the peaks of prevalence rates are mostly in the past except in Eastern Europe, where they are expected to peak in 2008. But owing in part to the life‐prolonging effect of antiretroviral therapy and to sustained population growth, the absolute number of infected individuals is expected to keep growing slowly in sub‐Saharan Africa and to remain near current levels worldwide, thus posing a continuing challenge to public health programs. No country is expected to see a decline in its population size between 2005 and 2050 that is attributable to high mortality related to AIDS.     

HIV/AIDS and Urbanization

It is well known that levels of HIV prevalence tend to be appreciably higher inurban areas. This article considers the reasons for this and shows that within world regions that are relatively homogeneous with respect to their experience of HIV/AIDS, variation in the level of urbanization corresponds to about one‐third of variation in estimated HIV prevalence. Furthermore, for populations in the world's worst‐affected area—eastern and southern Africa—there are signs that, partly by differentially raising urban death rates and depressing urban birth rates, HIV/AIDS is slowing the pace of urbanization. Finally, in countries with very high levels of HIV infection and relatively low birth rates, such as in South Africa, the urban sector will soon constitute a “demographic sink”—with death rates exceeding birth rates.     

Global Demographic Convergence? A Reconsideration of Changing Intercountry Inequality in Fertility

This research challenges the notion that the second half of the twentieth century was a period of global demographic convergence. To be sure, fertility rates fell substantially during the period, but with considerable un‐evenness. The declines in total fertility across population‐weighted countries were sufficiently disproportionate that intercountry fertility inequality, estimated using standard measures of inequality, did not begin to decline until at least 1995. Regression analysis also shows that only very recently did lagging countries begin to catch up with countries that began the transition to low fertility earlier. Contrary to findings on changing intercountry health inequality, sub‐Saharan Africa has had a greater impact on changes in fertility inequality than China. The trend in fertility inequality, where convergence is a relatively new phenomenon, stands in contrast to trends in inequality in other domains, such as income, education, and health.     

Adult mortality in sub-Saharan Africa: Evidence from demographic and health surveys

This article reports levels, trends, and age patterns of adult mortality in 23 sub-Saharan Africa countries, based on the sibling histories and orphanhood data collected by the countries' Demographic and Health Surveys. Adult mortality has risen sharply since HIV became prevalent, but the size and speed of the mortality increase varies greatly among countries. Excess mortality is concentrated among women aged 25-39 and among men aged 30-44. These data suggest that the increase in the number of men who die each year has exceeded somewhat the increase for women. It is time for a systematic attempt to reconcile the demographic and epidemiological evidence concerning AIDS in Africa.     

Rethinking the African AIDS Epidemic

Half the AIDS victims in the world are in East and Southern Africa, where adult HIV sero‐prevalence was 11.4 percent by the end of 1997 and over 25 percent in two countries of Southern Africa. HIV/AIDS infection is not the result of ignorance, as nearly everyone has sufficient knowledge about AIDS and how it is transmitted. The high levels of AIDS arise from the failure of African political and religious leaders to recognize social and sexual reality. The means for containing and conquering the epidemic are already known, and could prove effective if the leadership could be induced to adopt them. The lack of individual behavioral change and of the implementation of effective government policy has roots in attitudes to death and a silence about the epidemic arising from beliefs about its nature and the timing of death. International responsibility may have to be taken before the needed effective policies are put in place.     

Maternal mortality in South Africa: an update from the 2007 Community Survey

The 2007 Community Survey conducted in South Africa included questions on maternal deaths in the previous 12 months (pregnancy-related deaths). The Maternal Mortality Ratio (MMR) was estimated at 702 per 100,000 live births, some 30% more than at the 2001 census. This high level occurred despite a low proportion of maternal deaths (4.3%) among deaths of women aged 15–49 years, which is even lower than the proportion of time spent in the maternal risk period (7.6%). The high level of MMR was due to the astonishingly high level of adult mortality, which increased by 46% since 2001. The main reasons for these excessive levels were HIV/AIDS and external causes of death (accidents and violence). Differentials in MMR were very marked, and similar to those found in 2001 with respect to urban residence, race, province, education, income, and wealth. Provincial levels of MMR correlated primarily with HIV/AIDS prevalence. Maternal mortality defined as ‘pregnancy-related death’ appears no longer as a proper indicator of ‘safe motherhood’ in this situation.     

Comparison of household-survey estimates with projections of mortality and orphan numbers in sub-Saharan Africa in the era of HIV/AIDS

The United Nations publishes estimates of HIV prevalence, AIDS mortality, and orphan numbers for all countries of the world. It is important to assess the validity of these model-based estimates since they underpin much policy concerned with care and prevention. Household surveys that ask questions about the survival of children's parents (orphanhood) offer an independent source of data with which these estimates can be compared. Survey estimates of maternal and paternal orphans are significantly lower than model estimates for 40 surveys in 36 countries of sub-Saharan Africa (p < 0.001, p = 0.002). This is probably because adult mortality from causes other than AIDS is lower than assumed in the models, although under-reporting of orphanhood in surveys may also play a role. Reducing adult mortality from causes other than AIDS brings the model estimates into close agreement with the surveys. This suggests that the fraction of orphans attributable to AIDS is greater than estimated previously.     

The United Nations on the Demographic Impact of the AIDS Epidemic

A report prepared by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and released in Geneva on 27 June 2000 (just prior to the XIIIth International AIDS Conference held in Durban, South Africa) updates estimates of the demographic impact of the epidemic. It characterizes AIDS in the new millennium as presenting “a grim picture with glimmers of hope”—the latter based on the expectation that national responses aimed at preventing and fighting the disease are in some places becoming more effective. According to the report, which emphasizes the considerable statistical weaknesses of its global estimates, the number of people living with HIV/AIDS in 1999 was 34.3 million (of which 33.0 million were adults and 1.3 million were children under age 15; slightly less than half of the adults affected, 15.7 million, were women). Deaths attributed to AIDS in 1999 amounted to 2.8 million, bringing the total since the beginning of the epidemic to 18.8 million. These figures represent moderate upward revisions of earlier UN estimates shown in the Documents section of PDR 25, no. 4. The revised estimate of the number of persons newly infected with HIV in 1999 is, in contrast, slightly lower: 5.4 million, of which 4.7 million were adults and 2.3 million were women. An excerpt from the 135‐page Report on the Global HIV/AIDS Epidemic, focusing on countries in the worst‐affected area, sub‐Saharan Africa, is reproduced below. (Figures shown have been renumbered.)     

The effects of high HIV prevalence on orphanhood and living arrangements of children in Malawi, Tanzania, and South Africa

Using longitudinal data from three demographic surveillance systems (DSS) and a retrospective cohort study, we estimate levels and trends in the prevalence and incidence of orphanhood in South Africa, Tanzania, and Malawi in the period 1988-2004. The prevalence of maternal, paternal, and double orphans rose in all three populations. In South Africa - where the HIV epidemic started later, has been very severe, and has not yet stabilized - the incidence of orphanhood among children is double that of the other populations. The living arrangements of children vary considerably between the populations, particularly in relation to fathers. Patterns of marriage, migration, and adult mortality influence the living and care arrangements of orphans and non-orphans. DSS data provide new insights into the impact of adult mortality on children, challenging several widely held assumptions. For example, we find no evidence that the prevalence of child-headed households is significant or has increased in the three study areas.     

The Patterns of Disability in the Peripheral Neighborhoods of Ouagadougou,Burkina Faso,and the Male–Female Health‐Survival Paradox

Disability is a crucial health and social concern in sub‐Saharan Africa, where a high prevalence of disabling diseases is compounded with insufficient care provision. There is a need for detailed analysis of the disability patterns. We provide a gender‐specific picture for the population in peripheral Ouagadougou (Burkina‐Faso), based on six disability dimensions following the United Nations’ recommendations. We computed disability‐free life expectancy (LE) using the Health and Demographic Surveillance System (Ouaga HDSS) (n = 1 902). Women have a longer partial LE in the 20–79 age range (+3.3 years), half of this LE being spent with a disability, versus 31% of the LE for men. Limitations in mobility, cognition, and eyesight occur in midadulthood and result in a considerable disadvantage for women in the number of years with these limitations. These findings highlight disability patterns that are detrimental to social participation and claim for better screening and care, especially for women.     

Economic Growth and Child Undernutrition in sub‐Saharan Africa

Despite recent improvements in economic performance, undernutrition rates in sub‐Saharan Africa appear to have improved much less and rather inconsistently across the continent. We examine to what extent there is an empirical linkage between income growth and reductions of child undernutrition in Africa. We pool all DHS surveys for African countries, control for other correlates of undernutrition, and add country‐level GDP per capita. We find that a 10 percent increase in GDP per capita is associated with 1.5 to 1.7 percent lower odds of being stunted, 2.8 to 3.0 percent lower odds of being underweight, and 3.5 to 4.0 percent lower odds of being wasted. Other drivers of undernutrition, including relative socioeconomic status and mother's education and her nutritional status, are quantitatively more important. This suggests that further increases in GDP will have only a modest impact on undernutrition and broader interventions are required to accelerate progress.     

Late marriage and the HIV epidemic in sub-Saharan Africa

The causes of large variation in the sizes of HIV epidemics among countries in sub-Saharan Africa are not well understood. Here we assess the potential roles of late age at marriage and a long period of premarital sexual activity as population risk factors, using ecological data from 33 sub-Saharan African countries and with individual-level data from Demographic and Health Surveys (DHS) in Kenya and Ghana in 2003. The ecological analysis finds a significant positive correlation between HIV prevalence and median age at first marriage, and between HIV prevalence and interval between first sexual intercourse and first marriage. The individual-level analysis shows that HIV infection per year of exposure is higher before than after first marriage. These findings support the hypothesis of a link between a high average age at marriage and a long period of premarital intercourse during which partner changes are relatively common and facilitate the spread of HIV.     

The spread of primary schooling in Sub-Saharan Africa: implications for fertility change

In 1980 Caldwell hypothesized that the time of the onset of the fertility transition in developing countries would be linked with the achievement of “mass formal schooling.” This article applies Demographic and Health Survey data to assess schooling patterns and trends for 23 sub‐Saharan African countries, using the percentage of 15–19‐year olds who have completed at least four years of schooling as an indicator of progress in education. As background to that assessment, the article includes a review of the sparse literature on the links between children's schooling and fertility decline. The analysis strongly supports Caldwell's hypothesis with empirical evidence of the much stronger negative relationship between fertility decline and grade 4 attainment in those countries that have attained mass‐schooling levels than in those that have not yet achieved such levels.     

Prime-age adult mortality in sub-Saharan Africa: examining trends in Demographic and Health Surveys conducted between 1990 and 2014

Adult mortality rate is a critical indicator used to assess the level of national development in most sub-Saharan African countries. However, estimation of adult mortality rates requires comprehensive and accurate reporting of adult deaths, which is one of the challenges faced by most sub-Saharan African countries. Using data from Demographic and Health Surveys conducted between 1990 and 2014 in 25 countries in sub-Saharan Africa, we examine trends in all-cause prime adult mortality (measured by the probability of dying between exact ages 15 and 50) and sex differences in adult mortality by region. Our paper provides a basis for tracking progress in reducing adult mortality and improving overall health. The median probability of dying was 173 per 1000 for women in the latest surveys, an increase from 166 per 1000 during the initial surveys. The median value for men was 177 per 1000; a decrease from the initial surveys which was 202 per 1000. Across all countries, the average annual increase in the probability of dying was higher for women (1.08%) than men (0.49%). Intensive efforts are needed to improve adult survival and ensure that sub-Saharan Africa achieves the Sustainable Development Goals by 2030. In particular, efforts to mitigate the premature risk of dying among women need to be intensified.     

Popular Moralities and Institutional Rationalities in Malawi's Struggle Against AIDS

The AIDS epidemic in sub‐Saharan Africa is fertile ground for examining how moral evaluations evolve over time and across different settings. We compare the discourse on AIDS in Malawi as presented in the media with that of everyday conversations. Drawing on two sets of texts, newspaper articles and conversational journals, produced over a ten‐year period from 1999 through 2008, we analyze their moral injunctions, or what individuals should or should not do in response to the AIDS epidemic. The predominant injunctions in the early years in both sources were premarital abstinence and marital fidelity. Following the introduction of HIV testing and treatment, however, the discourses diverged. Discourse in the media turned toward moral injunctions requiring individuals to interact with authoritative institutions; thus the conceptual center of gravity of the struggle against AIDS in the media shifted from collectivities of individuals to collectivities of institutions. Rural Malawians, however, received these moral injunctions with great skepticism and continued to advise each other to prevent death by controlling one's sexual appetites.