Trends and Socioeconomic Gradients in Adult Mortality around the Developing World

We combine data from 84 Demographic and Health Surveys from 46 countries to analyze trends and socioeconomic differences in adult mortality, calculating mortality based on the sibling mortality reports collected from female respondents aged 15–49. The analysis yields four main findings. First, adult mortality is different from child mortality: while under‐5 mortality shows a definite improving trend over time, adult mortality does not, especially in sub‐Saharan Africa. The second main finding is the increase in adult mortality in sub‐Saharan African countries. The increase is dramatic among those most affected by the HIV/AIDS pandemic. Mortality rates in the highest HIV‐prevalence countries of southern Africa exceed those in countries that experienced episodes of armed conflict. Third, even in sub‐Saharan countries where HIV prevalence is not as high, mortality rates appear to be at best stagnating, and even increasing in several cases. Finally, the main dimension along which mortality appears to differ in the aggregate is by sex. Adult mortality rates in sub‐Saharan Africa have risen substantially higher for men than for women—especially so in the high HIV‐prevalence countries. On the whole, the data do not show large gaps by urban/rural residence or by school attainment.     

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.     

Urbanization as a Global Historical Process: Theory and Evidence from sub‐Saharan Africa

Urbanization has traditionally been understood as a byproduct of economic development, but this explanatory framework fails to account for the phenomenon of “urbanization without growth” observed in sub‐Saharan Africa throughout the 1980s and 1990s. In light of this apparent anomaly, I argue that urbanization is better understood as a global historical process driven by population dynamics associated with technological and institutional innovations that have substantially improved disease control and food security in urban settlements across the globe. These innovations first emerged in Europe in the eighteenth and nineteenth centuries and were subsequently diffused through colonialism, trade, and international development assistance. A range of qualitative and quantitative evidence is presented to demonstrate that this historically grounded theory of urbanization offers a more convincing explanation for the stylized facts of Africa's urban transition—and hence the process of world urbanization more broadly—than the traditional economic account.     

The Johannesburg Summit on Health and Sustainable Development

The World Summit on Sustainable Development was held in Johannesburg, South Africa, 26 August‐4 September 2002. The meeting was a follow‐up to the United Nations Conference on Environment and Development (UNCED) that took place in Rio de Janeiro in 1992 but with a mandate broader than that of the Rio conference: the Summit was to consider strategies toward sustainable development in all its dimensions. According to the opening paragraph of the Plan of Implementation adopted by the Johannesburg Summit, the Rio conference “provided the fundamental principles and the programme of action for achieving sustainable development.” But while reaffirming commitment to the Rio principles, the Plan states that it intends to “further build on the achievements made since UNCED and expedite the realization of the remaining goals.” A topic conspicuously missing from the deliberations of the Rio conference was population, even though rapid population growth has a plausible bearing on sustainable development and specifically on the problem of poverty, an issue at the center of the discussions concerning sustainability. It had been expected that Johannesburg would make amends for that omission. In the ten years between the two conferences, the size of the world's population increased by some 790 million persons. Of this growth, 754 million, or 95 percent, occurred in the countries the United Nations classifies as “less developed.” The population of these countries grew by 18 percent between the two conferences, as compared with a 3 percent growth in the more developed countries. The countries classified as “least developed“—a subset of the less developed countries consisting of 48 countries, predominantly African, with a 2002 population of nearly 700 million—grew during the interconference period by 29 percent. This record of population growth since the Rio conference may be supplemented by the projections of the United Nations up to 2050. The medium variant of these projections for the next 48 years envisages a slight population decline in the more developed countries and an addition of some 2 billion persons to the less developed group. For the least developed countries, the UN projects a population of more than 1.8 billion in 2050, some 164 percent larger than the current population size. Although the magnitudes of past population growth and its likely future dynamics are well known, they attracted very little attention at the Johannesburg meeting. The Johannesburg Declaration on Sustainable Development, a concise political document issued at the closing of the conference along with the Plan of Implementation, pledges “to place particular focus on, and give priority attention to, the fight against the worldwide conditions that pose severe threats to the sustainable development of our people.” It then proceeds to specifics: “Among these conditions are: chronic hunger; malnutrition; foreign occupation; armed conflicts; illicit drug problems; organized crime; corruption; natural disasters; illicit arms trafficking; trafficking, in persons; terrorism; intolerance and incitement to racial, ethnic, religious and other hatreds; xenophobia; and endemic, communicable and chronic diseases, in particular HIV/AIDS, malaria and tuberculosis” (Paragraph 19 of the Declaration,). The Plan of Implementation, a 27,000‐word document, was the main product of the Johannesburg meeting. Apart from a mention of the Cairo conference on Population and Development, the Plan's treatment of population issues is confined to health. The relevant section—section VI, titled Health and sustainable development—is reproduced below in full. (Paragraph numbers have been retained.) It presents a statement of goals couched in general exhortative terms (“integrate,”“promote,”“provide,”“improve,”“develop”), and specifies some quantitative targets, notably to reduce “by the year 2015, mortality rates for infants and children under 5 by two thirds, and maternal mortality rates by three quarters,” and “reduction of HIV prevalence among young men and women aged 15–24 by 25 per cent in the most affected countries by 2005 and globally by 2010.” The full text of the Plan can be found at http://www.un.org/jsummitlhtmlldocumentslsummit_docsl21Q9_planfinal.htm     

Natural Increase: A New Source of Population Growth in Emerging Hispanic Destinations in the United States

Updated US Census Bureau estimates and race/ethnic‐specific birth and death data for the post‐2000 period are used to highlight the increasing role of natural increase as an engine of population growth in emerging Hispanic destinations. Newly emerging Hispanic growth areas are distinguished from established and high‐growth areas from the 1990s. The findings document that recent Hispanic population gains have been generated increasingly by natural increase—the excess of Hispanic births over deaths. Hispanics accounted for 46 percent of the population gain and 53 percent of the natural increase in nonmetro America in 2000–2005. Yet, Hispanics represented only 5.4 percent of the nonmetro population in 2000. In metro areas, they accounted for 50 percent of the population gain and 47 percent of the natural increase, although they comprised only 14 percent of the metro population. Current trends suggest that the ascendancy of the US Hispanic population is likely to continue unabated, whether restrictive immigration legislation is enacted or not. The growth of the Hispanic population, caused increasingly by natural increase, has taken on a demographic momentum of its own.     

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.     

Alvin Hansen on Economic Progress and Declining Population Growth

The driving forces of economic growth, according to the mainstream of classical economic thinking, are threefold: technological innovations, the opening up of new territories and discovery of new resources, and increase in population. In interaction, in an entrepreneurial market economy, these forces generate growth not only in the aggregate but also per capita. Evidence of their power was seen in the long stretch of rising living standards in the West over the nineteenth century, despite the ups and downs of the business cycle. However, the economic experience of the interwar years, and in particular the Great Depression of the 1930s, suggested that the forces were largely spent and hence that future economic prospects were gravely imperiled. The Keynesian revolution in economics was a response to the evident malfunctioning of the capitalist economic system, although the policy recipes it offered (for increasing demand and investment to levels capable of generating an equilibrium consistent with full employment of productive resources, especially labor) by no means commanded unanimity. The most prominent American contributor to and spokesman for the new line of economic analysis—often called “the American Keynes”—was Alvin H. Hansen (1887–1975), who took up his professorship of political economy at Harvard in 1937, just after the appearance of Keynes's General Theory. In that post, which he held until his retirement in 1956, he was one of the most influential economists of the era as a theorist, policy adviser, and teacher. Hansen interpreted the economic problems of the 1930s not just as the manifestation of a particularly sharp cyclical downturn, but as evidence of secular stagnation caused by the closing of the economic frontier, sluggishness in technological innovation, and, not least, “a drastic decline in population growth.” This “stagnation thesis” is most succinctly set out in his presidential address to the American Economic Association, delivered in Detroit, 28 December 1938, under the title Economic Progress and Declining Population Growth. The address is re‐produced below from the March 1939 issue of the American Economic Review. (The opening paragraphs of the address, and two paragraphs, immediately preceding the closing paragraph, in which Hansen discusses changes in US national income in the 1930s, have been omitted.) Hansen's analysis of the effects of declining population growth in many ways echoes the thesis set out by Keynes in his seminal Galton Lecture delivered to the Eugenics Society in 1937 (reprinted in the Archives section of PDR 4, no. 3): a demographic slowdown decreases opportunities for profitable investments and increases levels of attempted saving, hence pushes the economy toward a low‐growth equilibrium at which resources are underutilized and unemployment is high. Hansen puts special emphasis on demographically induced shifts in the composition of output. He suggests that, beyond its direct positive effect on investment and output, population growth also has an indirect enhancing effect on these factors by facilitating technological progress–contrary to the “older Malthusian view.” In his policy proposals Hansen was more interventionist than Keynes, advocating a more intrusive government role in the economy as a possible means of escaping the vicious cycle of low demand and high unemployment. As to government action to reverse demographic trends seen as deleterious, neither Keynes nor Hansen argued for policies to increase fertility, presumably because they saw them as both inappropriate and, in comparison to remedial economic policy measures, inefficient or unfeasible. The demands of the war economy in the years following Hansen's address took care of the employment problem, and the immediate postwar decades brought the stimuli of pent‐up consumer demand, an outpouring of technological innovations, a reopening of the economic frontier produced by a more liberal trade regime, and, also, an acceleration of population growth. The result was rapid overall economic growth and increasing levels of per capita income. Keynesian demand management played some role in this economic success story: by the end of the 1960s even US President Richard Nixon pronounced himself a Keynesian. But it offered no remedy for the stagflation that eventually followed. The growth‐promoting recipes favored in the last decades of the century (especially in the most successful developing economies) were anything but Keynesian: limited government, fiscal restraint, and globalization. Yet recent and anticipated demographic trends, especially in Europe—notably fertility decline and population aging—make Hansen, once again, interesting reading. Commitments of the modern welfare state for health care, retirement pensions, and job security command wide approval, but they have boosted governments' weight in the economy and made labor markets inflexible, unemployment high, and retirement early—developments that may increasingly impose a brake on economic growth and on improvements of living standards. Reform measures to ease these burdens are, in principle, straightforward, but their immediate social costs are heavy and their rewards are delayed, hence resistance to reform is strong and growing. This is likely to stimulate the search for alternative policies that offer politically more palatable tradeoffs—some of which may turn out to have an unmistakably Hansenian flavor. As to future population trends, Hansen, despite his reference to a “drastic decline in population growth” based on a comparison of nineteenth‐ and twentieth‐century Western demographic change, envisaged a convergence to a stationary population or a tendency toward very slow decrease. Yet some economies are already locked into a demographic pattern that augurs sharper declines and more rapid population aging, enhancing the relevance of the issues posed by Hansen. In Germany, for example, in the absence of immigration, the population between ages 20 and 40 will decline from 21.6 million in 2005 to 16.3 million in 2025—a drop of 23 percent. Over the same time period, the population aged 60 and older will grow from 20.5 million to 25.8 million—an increase of 26 percent. Serious efforts to slow population decline and retard population aging by stimulating fertility would of course add another major burden to government budgets.     

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.     

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.     

The US National Intelligence Council on the Changing Geopolitical Landscape

The National Intelligence Council, a body reporting to the Director of National Intelligence, draws on expertise from within and outside the US intelligence community to assess strategic developments bearing on national security. In addition to its classified reports (notably the National Intelligence Estimates) the Council also issues unclassified versions of some of its work. In December 2004 it released a report, Mapping the Global Future, the outcome of a year‐long study known as the 2020 Project, looking at geopolitical trends in the world over the medium term. Robert L. Hutchings, the NIC's then chairman, writes in a preface that this report “offers a range of possibilities and potential discontinuities, as a way of opening our minds to developments we might otherwise miss.” It differs from a preceding NIC exercise, Global Trends 2015 (2000), in the wider range of experts consulted—preparatory workshops were conducted in a number of countries—and in the heavier store it places on formal scenario development. While the underlying scenario‐building techniques employed are not spelled out in the document (some are described elsewhere on the NIC's website), four specific “fictional scenarios” are selected to enliven the report: Davos World—illustrating “how robust economic growth, led by China and India, … could reshape the globalization process”; Pax Americana—“how US predominance may survive the radical changes to the global political landscape and serve to fashion a new and inclusive global order”; A New Caliphate—“how a global movement fueled by radical religious identity politics could constitute a challenge to Western norms and values as the foundation of the global system”; and Cycle of Fear—proliferation of weaponry and terrorism “to the point that large‐scale intrusive security measures are taken to prevent outbreaks of deadly attacks, possibly introducing an Orwellian world.” (The quotes are from the report's executive summary.) The excerpt reproduced below comprises the section of the report headed “Rising Powers: The Changing Geopolitical Landscape,” omitting text boxes and charts. The summary table appended is taken from the beginning of the document. The full report is available at http://www.cia.gov/nic/NIC_globaltrend2020.html .     

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.)     

First Politics,Then Culture: Accounting for Ethnic Differences in Demographic Behavior in Kenya

Ethnic differences in demographic behavior tend to be disguised behind analytically opaque labels like “district” or “region,” or else subjected to simplistic cultural explanations. Drawing on new political economy, sociological theory and the political science literature on sub‐Saharan Africa, this article proposes an alternative explanatory model and tests it empirically with reference to Kenya. Access to political power and, through power, access to a state's resources—including resources devoted to clinics, schools, labor opportunities, and other determinants of demographic behavior—are advanced as the key factors underlying ethnic differences. District‐level estimates of “political capital” are introduced and merged with two waves of Demographic and Health Survey data. The effects on models of contraceptive use are explored. Results confirm that measures of political capital explain residual ethnic differences in use, providing strong support for a political approach to the analysis of demographic behavior.     

Globalization and Inequality: A Norwegian Report

Is global inequality increasing? Some authoritative voices—for example, from the United Nations Development Programme—assert unequivocally that it is, and have carried popular belief with them. Others see a more nuanced and on balance a positive picture. Any attempt to answer the question must grapple with many conceptual and measurement difficulties. These are not wholly eliminated even if the inequality in question is narrowed to that among the per capita incomes of countries, ignoring intracountry differences in income. Disagreement about the empirical record has not impeded argument over causes. Globalization—the expansion of trade, investment, and technology flows among states that is making for a more integrated world economy—is invoked on both sides: seen by some as further marginalizing the world's poor, by others as offering a route out of poverty. The starkly different positions surface in the heated debates that have surrounded the World Trade Organization and the proposal for a Multilateral Agreement on Investment. The nature of trends in international inequality and the role in them of globalization are explored in a recent report issued by the Norwegian Ministry of Foreign Affairs, Globalisation and Inequality: World Income Distribution and Living Standards, 1960–1998 (October 2000), the summary from which is reproduced below. The report finds that global inequality between countries has decreased over the last four decades. Globalization may or may not have contributed to that outcome, but at least does not appear to work against it. In sum, “not everything has turned out badly; in fact there has—in spite of the setbacks in some regions and in spite of population growth—been considerable global progress during the last decades.” Given the chosen focus on inequality, there is little discussion in the report of that other dimension of global progress: changes in absolute income levels. But in assessing the implications of development for human welfare, the issue of economic growth and its relationship to globalization is clearly pertinent. Footnote 4 offers a passing glimpse of that dimension, referring to changes in absolute poverty. The World Bank's World Development Report 2000/2001 estimates that the number of people in absolute poverty (living on less than $1 a day) changed little between 1987 and 1998: it went from 1.18 billion to 1.20 billion. As the population grew, this meant a modest reduction in the proportion in absolute poverty in the world population (excluding the rich countries): from 28.3 percent to 24.0 percent. But in the East Asia and Pacific region—a region characterized by both rapid overall economic growth and increasing integration into the global economy—the number of poor dropped from 418 million to 278 million during the same period, with the proportion dropping from 26.6 percent to 15.3 percent. The report was commissioned from the Norwegian Institute of International Affairs (NUPI), and prepared by Ame Melchior, Kjetil Telle. and Henrik Wiig. It is available online both in its English version and in its original (and longer) Norwegian version—the former at http://odin.dep.no/ud/engelsk/publ/rapporter/index‐b‐n‐a.html , the latter through the Ministry's parallel Norwegian‐language site.     

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.     

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.     

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.     

Social Security in China: Government White Paper

The largest financial problem faced by many aging societies is how to support their older, retired members. That support was once wholly a matter for individual families, with perhaps a minimal safety net offered by charitable institutions. Increasingly, in the usual course of economic development, the requisite transfers become a responsibility of the state—financed either through tax revenues or by pensions offered by (or required of) employers. The combination of lengthening life expectancy at later ages and falling fertility, however, makes those transfers ever more onerous as fewer workers are expected to support greater numbers of retirees. The situation is often likened to the approaching collapse of a Ponzi scheme. Not surprisingly, governments see an attractive solution in what is in effect a reprivatization of responsibility—not back to the family but right to the individual, through a system of individual retirement accounts (albeit with considerable state supervision). The financial trans‐fers—savings and later dissavings—then take place over each person's life cycle. Establishing a social security system—through pay‐as‐you‐go transfers, individual retirement accounts, or some combination of the two—is a major institution‐building and administrative task for a developing country, the more so in the context of rapid population aging. China is certainly a case of rapid aging, with the proportion of the population over age 60 projected to rise from 10 percent in 2000 to 20 percent by 2025 and 30 percent by 2050. The document excerpted below, a 2004 White Paper issued by the government of China, describes China's current social insurance provisions and the proposed expansion of coverage (beyond government employees and the urban formal sector) over coming years. In urban areas, it envisages pension coverage of “all eligible employees,” with an increasing emphasis on personal accounts. (Not mentioned is the situation of the large “floating population” of informal rural‐to‐urban migrants.) In rural areas, reliance on family support perforce continues: in 2003, only 2 million farmers are reported as drawing old‐age pensions. A safety‐net provision for the destitute elderly with no family provides for another 2.5 million. The document mentions various experimental schemes in rural areas. One, for medical insurance, covers 95 million residents; another offers an annual “reward” to those over 60 who have only one child (or two girls). The excerpts comprise sections I (Old‐age Insurance) and X (Social Security in Rural Areas) and the Conclusion of the White Paper, China's Social Security and Its Policy, issued by the Information Office of the State Council, Beijing, September 2004.