The IMF on Policies Responding to Demographic Change

In its semiannual report World Economic Outlook, the International Monetary Fund presents its analysis of major economic policy issues and assessment of economic prospects, along with more detailed treatment of a selected current topic. The special topic in the 300-page report published in September 2004 is “The Global Demographic Transition,” treated in Chapter III of the document. An excerpt from the section of that chapter titled “Policies to Meet the Challenges of Global Demographic Change” is reproduced below with the permission of the IMF. Footnotes and the figure included in the excerpt have been renumbered. The title of Chapter III is “How Will Demographic Change Affect the Global Economy?” The tone of the discussion is set by the opening epigraph, a quotation from the UK's 1949 Report of the Royal Commission on Population: “It seems possible that a society in which the proportion of young people is diminishing will become dangerously unprogressive, falling behind other communities not only in technical efficiency and economic welfare, but in intellectual and artistic achievement as well.” Accordingly, the focus of the analysis, like that of the commentary by US Federal Reserve Chairman Alan Greenspan reprinted in the preceding Document item in this issue, is on the consequences of population aging and on the desirable policy responses to that process. The discussion broadly parallels Greenspan's but with a wider compass, including some consideration of the effects of aging in developing countries. It emphasizes the need for counteracting adverse effects of demographic change through a combination of policy measures, since “the size of the reforms” (such as increasing labor force participation, inducing later retirement, and attracting more immigrants) “that would be needed in any single area [is] sufficiently large that they would be politically and economically difficult to achieve.”     

Determinants of mortality transition in developing countries before and after the Second World War: Some evidence from Cuba

Few studies provide an insight into what factors contributed to declines in the mortality rates of developing countries before the Second World War. In this paper, statistics on causes of death from Cuba, particularly Havana, are used to investigate what may have been some of the principal determinants of mortality decline in the developing world before the arrival of modern drugs and insecticides. Trends in cause-specific mortality are examined in the light of Cuba's social, economic, medical and public health history. The Cuban experience strongly suggests that in this country public health and sanitary reforms and nutritional improvements were largely responsible for initial declines in mortality throughout the first half of the twentieth century. One important finding is that the impact of these reforms and improved nutrition was greatly influenced by prevailing economic conditions. Periods of economic prosperity facilitated declines in mortality; but in times of adversity, the reverse occurred. It appears that during prosperous periods the maintenance and expansion of public health and sanitary facilities were made possible by increased public and private revenues, and that individuals had access to a more abundant diet. The severe economic crisis of the Great Depression had the opposite effect. With the appearance of sulphonamides in the late 1930s, antibiotics, and residual insecticides and other specific measures at the end of the Second World War, the relevance of economic conditions as a determinant of mortality decline diminished. Although this analysis points to the aforementioned trends, the Cuban experience also suggests that other factors enter into the process of declining mortality and that this phenomenon can only be explained as the result of the complex interplay of many forces.     

WHO on Health and Sustainable Development

Ten years after the United Nations Conference on Environment and Development, also known as the “Earth Summit,” held in Rio de Janeiro in June 1992, the United Nations will convene another summit of world governments and other major actors to assess global change during the last decade. The meeting will be held in Johannesburg, 2–11 September 2002. One of the reports prepared for the 30 April–2 May 2001 session of the preparatory committee for the Johannesburg meeting discusses developments in global health. The report, prepared by the World Health Organization with “contributions from other United Nations agencies and international organizations” and formally presented as a Report of the Secretary‐General (E/CN. 17/2001 /PC/6), is reproduced below in full. It notes some of the remarkable gains in health during the past decade and, in greater detail, enumerates the major problem areas and outlines future trends and challenges. The document is available at « http://www.un.org/esa/sustdev/health.htm#doc ».     

Major Socioeconomic Driving Forces of Improving Population Health in China: 1978–2018

China's post-Cultural-Revolution reform generated rapid economic growth. But it also brought about major negative changes, especially in the early stage, which jeopardized population health and mortality gains. Nonetheless, improvements continued. China had achieved the Millennium Development Goal target 4 of reducing under-5 mortality by two-thirds well before the target year of 2015. Life expectancy continued to rise and reached 76.6 years by 2018, notably higher than the world average and that recorded in many countries with similar per capita GDP. By describing China's recent economic growth, the rebuilding of nationwide health insurance systems, the development of medical financial assistance, and poverty alleviation programs, this paper shows how these improvements were achieved. Vulnerability to health and mortality risks has been reduced; the availability of, and people's access to, health insurance have increased; and better medical treatments and health services have become available and accessible. These macro-socioeconomic determinants have played the central role in achieving further population health and mortality progress in China in the past four decades.     

Lessons from the healthy cities movement for social indicator development

The author investigates emerging developments of social indicators through the experience of a health planning initiative begun in 1986 under the coordination of the World Health Organization (Europe). By 1993 over 400 municipalities in first world countries had voluntarily committed themselves to participation. The paper results from interviews and reviews of some participants' programs and materials, with significant reliance upon material from Canada and the coordinating WHO office. The author divides indicator development into political and technical components, stressing the former. He makes nine principal conclusions relating to indicators' success: (1) three stages of indicator development are understanding, consensus and commitment; (2) indicators must be grounded in target population's reality; (3) indicators are historical artifacts; (4) programs must be in place that make indicator need apparent; (5) process is product; (6) new skills must be supplied; (7) indicators are client-driven; (8) good process protects indicators' integrity from inappropriate influence; and (9) quality is a culturally-derived value defying aggregation.     

Reproduction,Compositional Demography,and Economic Growth: Family Planning in England Long Before the Fertility Decline

This article offers a radical reinterpretation of the chronology of control over reproduction in England's history. It argues that, as a result of post–World War II policy preoccupations, there has been too narrow a focus in the literature on the significance of reductions in marital fertility. In England's case this is conventionally dated to have occurred from 1876, long after the industrial revolution. With a wider angle focus on “reproduction,” the historical evidence for England indicates that family planning began much earlier in the process of economic growth. Using a “compositional demography” approach, a novel social pattern of highly prudential, late marriage can be seen emerging among the bourgeoisie in the course of the eighteenth and early nineteenth centuries. There is also evidence for a more widespread resort to such prudential marriage throughout the population after 1816. When placed in this context, the reduction in national fertility indexes visible from 1876 can be seen as only a further phase, not a revolution, in the population's management of its reproduction.     

Bertil Ohlin on Population,Trade, and Territorial Expansion

The international economic problems of the 1930s–in the aftermath of World War I and the depression—at first sight have few resonances with the present day. The leading powers of the time protected their industries behind high tariff walls. Most of them possessed colonies or were intent on regaining those lost in the war. Restoration of the free‐trade regime of the decades prior to 1913, and creation of a new financial architecture to support it, seemed a remote prospect. In all kinds of ways the post‐World War II and especially the post‐Cold War world is in vastly better shape. Yet some of the themes of the earlier period remain relevant. The colonies are gone and territorial expansion is virtually inadmissible, but the options for dealing with international imbalances in factor supplies and factor prices are otherwise the same: international trade, capital flows, and migration. The insight that international trade and international movements of productive factors could be substitutes owes much to the work of the Swedish economist Bertil Ohlin. Ohlin's magnum opus. Interregional and International Trade (1933), building on earlier work of Eli Heckscher, developed what became known as the Heckscher–Ohlin model of international trade. In its simplest form it described trade in a two‐region, two‐factor, two‐good economic system. With subsequent generalizations, the theory accommodated not just trade in goods but also movement of factors. Capital flows were principally of interest, but labor flows were formally analogous. The practical differences between the two, of course, were considerable: migration was not an acceptable mode of factor price equalization. Nor is it today, when worries about rapid population growth attach to poor countries rather than (as they did in the 1930s, if speciously) to industrialized states claiming lebensraum. Indeed, it is less so, since the population sizes of the sending countries are multiples of their 1930s levels and high migrant flows encounter resistance in the receiving countries. The passage reproduced below comes from a project on economic reconstruction and financial stabilization organized by the Carnegie Endowment and the International Chamber of Commerce. One output of this project was a volume International Economic Reconstruction: An Economists' and Businessmen's Survey of the Main Problems of Today (Paris: International Chamber of Commerce, 1936), over half of which consisted of a study entitled Introductory Report on the Problem of International Economic Reconstruction, by Ohlin. The excerpt is part of Chapter 7 of this report: The Problem of “Overpopulation,” Colonies, Markets and Raw Materials. Bertil Gotthard Ohlin (1899–1979) had a distinguished career as a politician as well as economist. He was a long‐time member of Sweden's parliament, in which he led the Liberal Party—mostly in opposition. During 1944–45 he was Minister of Trade. In 1977 he received the Nobel prize in economics (together with James Meade) for contributions to the theory of international trade.     

Period‐Based Mortality Change: Turning Points in Trends since 1950

We investigate a major turning point in mortality trends at adult ages that occurred for many low‐mortality countries in the late 1960s or early 1970s. We analyze patterns of total and cause‐specific mortality over the past 60 years using data from the Human Mortality Database and the World Health Organization. We focus on four broad categories of causes of death: heart diseases, cerebrovascular diseases, smoking‐related cancers, and all other cancers. We use a two‐slope regression model to assess the timing and magnitude of turning points in mortality trends over this era, making separate analyses by sex, age, and cause of death. The age pattern of temporal changes is given particular attention. Our results demonstrate convincingly that period‐based factors were very significant in the onset of the “cardiovascular revolution” in the years around 1970. In general, although cohort processes cannot be ruled out as a driver of mortality change in recent decades (especially for mortality due to smoking‐related cancers), the evidence reviewed here suggests that period factors have been the dominant force behind the mortality trends of high‐income countries during this era.     

BOOK REVIEWS

Books reviewed in this article: Samuel H. Preston, Patrick Heuveline, And Michel Guillot, Demography: Measuring and Modeling Population Processes Bobbi S. Low, Why Sex. Matters: A Darwinian Look at Human Behavior Linda Mealey, Sex Differences: Developmental and Evolutionary Strategies Harriet B. Presser and Gita Sen (Eds.), Women's Empowerment and Demographic Processes: Moving Beyond Cairo World Health Organization, The World Health Report 2000: Health Systems: Improving Performance John Bongaarts and Rodolfo A. Bulatao (Eds.), Beyond Six Billion: Forecasting the World's Population John D. Early and John F. Peters, The Xilixana Yanomami of the Amazon: History, Social Structure, and Population Dynamics     

Excess mortality of girls in the Middle East in the 1970s and 1980s: Patterns,correlates and gaps in research

Abstract. Comparative research on girls' excess mortality in the Middle East is rare. Estimates from the United Nations suggest that absolute excess mortality of girls was not universal in the 1970s and was uncommon by the 1980s. Compared with historical Northwest Europe at similar levels of boys' under-five mortality, however, girls' under-five mortality was high in both periods. Studies of the allocation of food and health care suggest that parents invested less and provided less curative care to girls than boys where girls' excess mortality was greatest. Urbanization and women's relative economic opportunity account for much of the variation in relative mortality. Unexplained excess mortality of girls in the Middle East compared with historical Northwest Europe may be attributable to differences in socio-cultural, political, and economic systems that influence the forms of discrimination exercised against girls; however, inadequate measurement of these variables limits their consideration in comparative research.     

Cross-National Sources of Health Inequality: Education and Tobacco Use in the World Health Survey

The spread of tobacco use from the West to other parts of the world, especially among disadvantaged socioeconomic groups, raises concerns not only about the indisputable harm to global health but also about worsening health inequality. Arguments relating to economic cost and diffusion posit that rising educational disparities in tobacco use—and associated disparities in health and premature mortality—are associated with higher national income and more advanced stages of cigarette diffusion, particularly among younger persons and males. To test these arguments, we use World Health Survey data for 99,661 men and 123,953 women from 50 low-income to upper-middle–income nations. Multilevel logistic regression models show that increases in national income and cigarette diffusion widen educational disparities in smoking among young persons and men but have weaker influences among older persons and women. The results suggest that the social and economic patterns of cigarette adoption across low- and middle-income nations foretell continuing, and perhaps widening, disparities in mortality.     

Fertility in Kenya and Uganda: A comparative study of trends and determinants

Between 1980 and 2000 total fertility in Kenya fell by about 40 per cent, from some eight births per woman to around five. During the same period, fertility in Uganda declined by less than 10 per cent. An analysis of the proximate determinants shows that the difference was due primarily to greater contraceptive use in Kenya, though in Uganda there was also a reduction in pathological sterility. The Demographic and Health Surveys show that women in Kenya wanted fewer children than those in Uganda, but that in Uganda there was also a greater unmet need for contraception. We suggest that these differences may be attributed, in part at least, first, to the divergent paths of economic development followed by the two countries after Independence; and, second, to the Kenya Government's active promotion of family planning through the health services, which the Uganda Government did not promote until 1995.     

The impact of women's status on infant mortality rate: A cross-national analysis

A number of prior studies have attempted to account for cross-national differences in infant mortality rate using a variety of economic, demographic, and health related variables. These studies have given relatively little attention to the impact of predictors measuring the status of women. The present study, based on a sample of 96 less developed countries circa 1990, tests a series of hypotheses derived from gender stratification theory and industrialism theory. Evidence is presented of an inverse relationship between the status of women and infant mortality rate. The present study shows that it makes a difference whether we use relative or absolute measures of women's status and it shows that in addition to women's educational status, other dimensions of women's status particularly economic status and autonomy are also important predictors of infant mortality rate.     

Public policy and the socioeconomic mortality differential in infancy

This paper discusses some of the findings and policy implications of a recently completed study of socioeconomic differences in infant mortality in eight metropolitan areas of Ohio at three points in time. The study revealed that, in spite of a considerable decline in the overall rate of infant mortality since 1960, the inverse socioeconomic differential remains as wide as ever. This clearly suggests that, although maternal and child health has improved overall, the lower economic groups in our society still do not have equal access either to health care or to other amenities essential to the maintenance of good health. Moreover, consideration of recent and current policy proposals with respect to welfare programs in general, and maternal and child health care programs in particular, leads to the conclusion that this situation is not likely to change in the near future. Finally, some policy recommendations for enhancing the health status of low-income families are offered.The research on which this paper is based has been supported by the Maternal and Child Health and Crippled Children's Services Research Grants Program (Grant MCJ-390520-01); Bureau of Community Health Services, HSA, PHS, DHHS.     

The Council of Economic Advisers on the Changing American Family

The 2000 Annual Report of the US Council of Economic Advisers (a document exceeding 300 pages, formally an Annex to the Economic Report of the President Transmitted to the Congress February 2000, Washington, DC: US Government Printing Office) devotes considerable space to a discussion of the demographic and economic changes affecting families in the United States. Excerpts reproduced below from the first part of Chapter 5, titled “The Changing American Family,” examine the relevant trends in a broad historical perspective, drawing on data in some cases spanning the entire twentieth century. The second part of this chapter discusses the “money crunch”: financial constraints “that still burden many families despite the remarkable growth in the American standard of living,” and the “time crunch”: shortage of time devoted to family needs “that results from the increased participation of parents, especially mothers, in the paid labor market.” Policies designed to address these problems are also discussed in the second part of the chapter.     

The HIV/AIDS Epidemic at the End of 1999

The status of the global HIV/AIDS epidemic is summarized in a report entitled AIDS Epidemic Update: December 1999, issued by the United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization. The generally bleak but regionally diverse picture is conveyed in the series of bulleted statements at the beginning of the report and in two summary tables, reproduced below. The rest of the report discusses the regional situations in more detail. An earlier UNAIDS and WHO surveillance report (June 1998) was excerpted in the Documents section of PDR 24 (3).     

Measures and effectiveness in controlling omission of reports on infant deaths in Shanghai metropolitan areas]

The infant mortality rate is a sensitive indicator of a country's or area's economic, cultural, and health care conditions, and in particular, it reflects the quality of health care for women and young children. Since liberation, great progress has been achieved in Shanghai's health and medical care in general as well as in health care for women and young children, and the infant mortality rate has dropped notably. However, the omission of reports on infant deaths is still a very serious problem. In order to control such omissions in reporting, the Shanghai municipal government and Department for Public Health have improved the methods of reporting deaths. Health care units are required to fill out a report on births and deaths, and census registers in the city government are responsible for registering all new births and deaths and preparing complete statistics on new births and deaths. At the end of each year, special investigators are sent to various hospitals to check on omissions of reports on infant deaths and they also help households to report infant deaths to census registers. The new measures have proved to be very effective. According to a new report released in 1980, the omission of reports on infant deaths has been reduced by 94.01% as compared with the 1972 statistics.