|
Population growth and decline
The difference between the number of births and deaths occurring in a given period of
time is the natural population growth. This natural increase excludes changes in a
population size due to migration. For the sake of comparison, natural population growth
is usually expressed as a percentage increase with respect to the population existing at the beginning of the time
period considered (see Annex A). A three percent rate of growth translates into a
population doubling time (i.e., the time it would take for a population to double
assuming constant rates of growth) of 23 years.
Examples of extreme population growth values currently affecting some developing
countries are reported in the last two columns of Table 2.2 (below). The table shows that for
most of the selected countries, the crude birth rate is stationary or decreasing.
Meanwhile, from 1960 to 1994, the crude death rates and especially the under-five
mortality also decreased markedly in all of these countries. This pattern suggests that
natural population growth in these regions has probably been related more to a decrease
of mortality (particularly in the early years of life) than to an increase in natality and
fertility. In the 1990s, this trend has reversed in some countries due to HIV/AIDS, e.g.,
in Uganda, where the average life expectancy from birth has now dropped into the mid-40s (PRB, 1996).
Table 2.2:
Comparison of mortality and population growth indicators -- in 12 countries with high U5MRs and above-average annual growth rates
| Country |
Under-5 Mortality
Rate* |
Crude Death Rate |
Crude Birth Rate |
Annual Growth
Rate |
| Year |
1960 |
1994 |
1960 |
1994 |
1960 |
1994 |
1960 |
1994 |
| Very high U5MR countries (over 140) |
| Niger |
320 |
320 |
29 |
19 |
54 |
53 |
2.5 |
3.4 |
| Somalia |
294 |
211 |
28 |
19 |
50 |
50 |
2.2 |
3.1 |
| Liberia |
288 |
217 |
25 |
14 |
50 |
47 |
2.5 |
3.3 |
| Tanzania |
249 |
159 |
23 |
14 |
51 |
43 |
2.8 |
2.9 |
| Nigeria |
204 |
191 |
24 |
16 |
52 |
45 |
2.8 |
2.9 |
| Gabon |
287 |
151 |
24 |
16 |
31 |
37 |
0.7 |
2.1 |
| Uganda |
218 |
185 |
21 |
19 |
50 |
52 |
2.9 |
3.3 |
| Pakistan |
221 |
137 |
23 |
9 |
49 |
41 |
2.7 |
3.4 |
| High U5MR countries (over 140) |
| Kenya |
202 |
90 |
22 |
12 |
53 |
45 |
3.1 |
3.3 |
| Nicaragua |
209 |
68 |
19 |
7 |
51 |
41 |
3.2 |
3.4 |
| Iraq |
171 |
71 |
20 |
7 |
49 |
38 |
2.9 |
3.1 |
| Zimbabwe |
181 |
81 |
20 |
12 |
53 |
39 |
3.3 |
2.7 |
* Calculated on the basis of crude birth and death rates
Source: UNICEF, 1996
A negative rate of population growth, i.e., a natural decline in population size
(sometimes called a 'negative increase'), occurs when the number of deaths exceeds that
of births. This category of 'natural' population decline is separate from changes in
population numbers due to migration or displacement. As human populations in the
developing world generally tend towards increasing in size, negative rates of population
growth are often the result of natural or man-made disasters (see Case Example 2.4).
|
Case Example 2.4 : Gold, slavery, and epidemics - decrease of the Amerindian population after the Hispanic Conquest
The "great dying" first affected the islands of the Caribbean. It then spread to the
mainland shores of the Middle and South American lowlands in general. Finally, it
made inroads into the highlands, which had supported the great polities of the Aztec,
Chibcha, and Inca. Hispañola (Santo Domingo) had about a million inhabitants in 1492,
when first contacted by Columbus. By the end of the 1520s only insignificant numbers
survived.
A primary cause of the deaths and population decline was the spread of Old World
pathogenic organisms to which the New World populations had not yet developed some
immunological defenses. The impact of smallpox and measles, often complicated by
respiratory ailments, was intense over wide areas. There were as many as 14 major
epidemics in Mesoamerica, and perhaps as many as 17 in the Andean region between
1520 and 1600. Other illnesses had more localized effects. On the Mesoamerican coast,
malaria - probably introduced by mosquitoes traveling on the ships of Spanish
merchants and soldiers from Italy - caused regional havoc and then spread through the
tropical lowlands.
One must ask also about the social and political conditions that permitted the pathogens
to proliferate at so rapid a rate. On the islands and in the borderlands of the Caribbean,
these conditions clearly included the extensive use of slave labor in the search for gold,
and (after 1494) a massive intensification of slave raiding and slavery. Nicaragua alone
lost, in the first half of the sixteenth century, an estimated 200,000 inhabitants to slave
raiders, who sold their prey in the Caribbean islands, Panama and Peru.
Whatever the baseline figure, the combined effects of 'new' diseases and colonization
catastrophically decimated the population. The pre-Hispanic population of Mesoamerica
has been estimated at 25 million, but it fell to a low point of 1.5 million by 1650,
recovering only slowly thereafter.
From: Wolf, 1982
|
Some population declines have been linked with severe environmental degradation, as
for the lowland Maya of Yucatan during the ninth century AD (see Case Example 2.15).
More recently, genocide (i.e., the intentional destruction of a given population, often on
the basis of ethnic hatred) has caused substantial population losses. 'Natural' population
declines have also been observed in some affluent communities in developed countries
(see Case Example 2.5).
|
Case Example 2.5: Negative natural growth and child-rearing costs in northern and central Italy
In 1993, in the industrial and affluent areas of northern and central Italy, the balance
between births and deaths was negative, i.e., approximately minus 78,000. This trend
seems to be related to both economic and behavioral factors, as well as to the wide
availability of family planning services.
In this setting, the desired pattern of consumption and the cost of living require a level
of income which can only be achieved if both husband and wife have full-time jobs. The
average number of years of education (including high school and university) delay the
integration of young adults into the workforce, postponing to the third decade of life the
age at which a married couple feels sufficiently self-reliant to engage in parenthood. In
fact, the socio-economic cost of child-rearing has greatly increased in the last decades.
As a consequence of this economic trend, fertility is no longer a way to gain social
status, and parenthood is no longer perceived as a basic condition of adult life. Most
married couples feel comfortable with having just one child; others completely ignore
the biological and psychological drive towards reproduction and renounce parenthood.
Adapted from: Solinas, 1992
|
Population growth may also be equal to zero. The zero-growth situation, frequently
termed 'population stabilization', develops when the difference between the numbers of
live-births and deaths in a given period of time is equal (or nearly equal) to zero. This situation is an index of balanced
population dynamics, which, in fact, is what has happened for most of mankind's
evolutionary history, with high child mortality balanced against high fertility. Today, births and deaths tend to balance in populations
with an older age distribution in which each couple averages only two children that
survive to reproductive age. This kind of zero natural growth, achieved by a reduction in
both mortality and fertility attained throughout the globe, would be a powerful
component of sustainable livelihood.
Population and culture: fertility and contraception
High numbers of offspring are encouraged in many rural communities. In fact, most
ethnic and peasant groups world-wide set a high value on fertility. Among the Akan of
Ghana, for example, a woman who gives birth to ten children is rewarded with 'the
tenth-child sheep', so that she would not stop at the seventh, eighth, or ninth child.
In settings where no social security system is available, sons and daughters are the only security a parent has in his/her old age. Moreover, beginning in
childhood, sons and daughters often work to provide additional income for the household. Once grown up, they play a major role in
strengthening, through marriage, the social links between their parents' household and other members of the community. This often represents
important economic and social advantages for the families involved, in terms of capacity to mobilize extra labor, exchange of goods and
services, maintenance of property rights, social status, etc.
The economic and social advantages of high fertility are often embedded in deeply
rooted social and religious values. With the exception of Catholicism, no major
religious tradition contains an unequivocal and universally accepted prohibition against
contraception. Even so, many traditional communities still rely on religion for
arguments opposing the limitations on fertility and family size advocated by external
development agents. For example, while religious scholars are divided on the attitudes
of Islam towards contraception, the widespread belief among many practicing Muslims
is that modern contraception is incompatible with religious teachings.
Until recently, only Western Europe and societies with European ancestry in the New
World looked negatively on fertility. These societies are characterized by nuclear
families, late marriages and parents contributing to their children's economic well-being: all factors that would favor smaller families and lower population growth (see
below, Case Example 2.5). In contrast, the predominant family pattern in much of rural Asia and Africa is extended
families, early marriages and 'adult' children who economically assist their parents.
These factors tend to encourage high fertility and high population growth rates. In both cases, cultural attitudes toward fertility appear based on the predominant social
and economic conditions in a given community. In the long run, both cultural systems
are unsustainable, because growth in either population or consumption cannot continue
indefinitely into the future.
|
Case Example 2.5: Negative natural growth and child-rearing costs in northern and central Italy
In 1993, in the industrial and affluent areas of northern and central Italy, the balance
between births and deaths was negative, i.e., approximately minus 78,000. This trend
seems to be related to both economic and behavioral factors, as well as to the wide
availability of family planning services.
In this setting, the desired pattern of consumption and the cost of living require a level
of income which can only be achieved if both husband and wife have full-time jobs. The
average number of years of education (including high school and university) delay the
integration of young adults into the workforce, postponing to the third decade of life the
age at which a married couple feels sufficiently self-reliant to engage in parenthood. In
fact, the socio-economic cost of child-rearing has greatly increased in the last decades.
As a consequence of this economic trend, fertility is no longer a way to gain social
status, and parenthood is no longer perceived as a basic condition of adult life. Most
married couples feel comfortable with having just one child; others completely ignore
the biological and psychological drive towards reproduction and renounce parenthood.
Adapted from: Solinas, 1992
|
Throughout history, the high fertility of human beings has been balanced by both
natural and cultural controls. Natural controls include biological determinants of natural
fertility, such as women's monthly menstrual cycles, their nutritional status, and
infectious or degenerative diseases. Culture, which broadly includes clusters of shared
values and behaviors, controls fertility through practices related to conception, as well
as to the care of fertile and pregnant women, infants and children. Cultural controls
affect population dynamics in two complementary ways:
- by determining and shaping behaviors that result in the reduction of women's
natural potential for fertility, e.g., late age of marriage and first births, prolonged breast-feeding, prolonged separation of parents after a birth, use of family planning methods,
etc.
- by defining the sets of values, beliefs, and specific attitudes that influence the
context of reproduction and parenting, e.g., perceptions of the best age to start
parenting, stigmatizing new pregnancies that occur when the previous child is still
breast-feeding, giving special names to persons who bear twins or triplets, etc.
Cultural regulation of sexual activity (coitus) is the most direct means of controlling
conception. In all societies, this is achieved through rules which limit potential sexual
relationships (e.g., forbidding incest). Age-at-marriage and sexual taboos preventing
intercourse during specific periods (for instance, soon after the birth of a child) can be
considered mechanisms for controlling sexual activity, and therefore the potential for
reproduction.
A second way of controlling conception by cultural means is contraception (i.e.,
practices which reduce the probability of a woman becoming pregnant without
necessarily preventing sexual intercourse). Contracep-tion also includes regulating
sexual activity based on scientific or folk knowledge of reproductive anatomy and
variations in fertility during the menstrual cycle, as well as contraceptive herbs and
medications.
An important means of controlling conception, practiced by most pre-industrial
societies, is prolonged breast-feeding. Folk wisdom in many regions includes awareness
of the relationship between breast-feeding and length of post-partum amenorrhea (i.e.,
the time following delivery during which a woman's menstrual cycle is interrupted).
Research studies have shown that under favorable conditions, prolonged breast-feeding
can result in birth-spacing intervals of three or more years, with a reliability comparable
to modern medical and chemical contraceptives (Short, 1984).
In addition, harsh living conditions tend to affect fertility. According to Harris and Ross
(1987), the way in which women are physically treated can raise or lower the age of the
first menstruation, lengthen or reduce the period of adolescent sterility, increase or
decrease the frequency of amenorrhea, and hasten or retard the upper limits of the
fertility age. Variation in nutritional intake, physical workload and harsh living
conditions may decrease fertility and increase the risks of natural abortion, maternal
mortality and infant mortality (Bongaarts, 1982; Hamilton et al., 1984).
In many rural communities, various traditional (non-medical) forms of planning and
controlling births are far more prevalent than the modern methods. In fact, most
individuals or couples who utilize modern methods are also likely to be using one or
more of the traditional methods. Thus, measurements of the impact of family planning
interventions that are only linked to levels of acceptance or use of specific modern
methods may be of little value in determining actual practices that are regulating
population size in a community.
Over-emphasis on modern methods can also lead to discounting traditional values in the
community (Mamdani, 1972). A good method of assessing the effects of any intentional
change in population control-related behaviors in a community is to measure birth
intervals, i.e., the average period of time between consecutive births among those
women who are having children in the community. This can be a very sensitive measure
at local levels, able to show changes rapidly and inexpensively.
Intra-uterine death and spontaneous abortion are high among human females, i.e., up to
25 percent of pregnancies during the first month (MacCormack, 1982). Although this
pattern is partly due to natural anatomical and physiological factors, such a high
abortion rate cannot be explained without taking into account the effects of harmful
cultural practices. Among such behaviors are not reducing the workload of women
during the early months of pregnancy or not providing them with a high-quality diet.
Additionally, intentional abortions (by mechanical or chemical means) are practiced in many cultures as a child-spacing device (Devereux,
1976). The impact of these practices may reach far beyond the direct effects on the new
life - unsafe abortions can cause anatomical and physiological damage that reduces a
woman's fertility.
More or less deliberate infanticide has also been widely reported in historical and anthropological literature. In addition to direct killing, at least five other
forms of infanticidal behavior occur in several cultures: placing an infant in dangerous
situations; abandonment with little chance of survival; negligence resulting in accidents; excessive physical punishment;
and lowered biological support (Scrimshaw, 1983). Not only infants, but also children
are the victims of direct or indirect forms of homicide (Dickemann, 1984; see also Case
Example 2.6).
|
Case Example 2.6: Beliefs, parents' attitudes and childhood deaths among the Achuar
The Achuar (a slash-and-burn horticultural society of the Pastaza watershed in the
Ecuadorian and Peruvian Amazon) consider the first year of life of a new-born baby as
an extension of his or her intra-uterine existence. Infants are thus perceived as being not
only completely dependent on the mother, but also as weak, incomplete and not yet full
sons or daughters. Until they are given a personal name, their social existence is not
even acknowledged.
Achuar infants are assumed to be exposed to a vast amount of risks posed by the magic
powers of almost all objects, plus the behaviors of their parents. Most infant illnesses
are believed to occur after parents breach some of the infinite eating and behavioral
taboos they must respect in order to ensure an infant's health and survival. The death of
a breast-fed child is most often attributed to a ritual that has not been correctly followed
by the parents. Even so, no blame is given to the mother or the father of the dead baby:
everybody understands that the number of taboos is so great that it would be impossible
to live without breaking some of them. Thus, when infants die, limited mourning rituals
are carried out in a rapid fashion. Within days, nobody in the community seems to be
further interested in the issue.
This attitude is in strong contrast to the anxiety which surrounds illness in an already
weaned, but walking and talking child (i.e., a being who has a personal name and who is
a 'real' son or daughter). A sick child is a major event for a household: huge amounts of
money and time are invested in attempts to heal the child through modern medicine or
expensive shamanistic rituals. The death of such a child is often attributed to enemies'
witchcraft. Long mourning rituals are performed, and the warriors of the community
may discuss for weeks, or even months, the possibility of taking revenge on the witch
suspected of being responsible for the death.
However, as soon as the symptoms subside and the child recovers, the daily routine of
child-rearing is resumed. Weaned children are left alone for the entire day with a sister who is
only two to three years older. During meals, they are not entitled to their own portion of
food but must share those of the parents, kinsmen and visitors. Customary rules are
enforced by threats, physical punishment and, in cases of severe infringement,
administration of intoxicating datura roots. Accidents both within and outside the home
are quite common, as is retaliation against small children by elder brothers and sisters.
Considering infants as not fully human and accepting their death as destiny is perhaps a
way of culturally and psychologically managing the fragility and precariousness of the
early months of life and the high infant mortality affecting tropical rain forest societies
(more than 150 deaths per 1,000 live births). Severe and somewhat inconsistent child
training may, on the other hand, be interpreted as a way of promoting acquisition of
behaviors and skills which are adaptive with respect not only to the harsh physical
environment with which the Achuar must deal, but also to the conflictive, violent and
unsafe social arena in which adult social life unfolds. The Achuars' version of the
Darwinian principle of survival of the fittest may indeed have contributed to limiting
population growth over the centuries.
|
Concern over population growth is not new to the domain of public health. Since the late 1960s, when the assumption that a decrease in infant and child
mortality would automatically lead to a reduction in the birth rate proved to be
questionable (see Box 2.5), a family planning component has been added to most
national health service delivery systems. In 1978, family planning was acknowledged
by WHO as a basic element of comprehensive Primary Health Care, and some years
later it was endorsed by UNICEF as a key component of its child survival strategy.
|
Box 2.5: How can the birth rate be reduced?
There is a widespread assumption that the necessary and sufficient condition for
reducing the birth rate is to reduce the child death rate. The reasoning goes that if
families see that their children no longer die, they will have fewer of them.
Preston (1978) was among the first to question this notion. He called it a "hopeful
policy declaration resting on a thin research base" and wondered how much mortality
decline can be expected to translate into fertility decline, and the strength of this relation
in "setting levels of mortality control." An additional child death in a family leads, on
average, to far less than one additional birth, especially in high-fertility pre-transitional
societies. He concluded: "The picture is not attractive for those who look to mortality
reduction as a means to reduce fertility through familial effects, let alone those who
advocate such measures as a means to reduce growth rates."
A fall in the birthrate leading to a demographic transition seems to require the
harnessing of social and economic gains consequent to poverty reduction and socio-economic
development. Unfortunately, serious constraints prevent such development from
happening and thus the birth rate from falling. The factors include lack of agricultural
land and its poor quality and irrigation potential, poor supplies of energy and other raw
materials, limited access to education and jobs, and lack of political representation.
There is also the economic stranglehold exerted by the rich over the poor, and by the
industrial over the developing world; the time needed for structural and cultural change
must also be taken into account. For many countries, these constraints appear to be so
great that a demographic transition is unlikely to occur before excessive pressure is
exerted on the ecological support system.
From: King, 1990
|
Nonetheless, in many countries - particularly those in Sub-Saharan Africa - the short-term impact of family planning programs on fertility rates has proven to be limited. Cultural acceptance, physical and financial
accessibility for users, and costs of service delivery have been shown to be major
constraints. Actual use of modern family planning technologies is the result of complex
socio-cultural changes that sometimes unfold through generations.
Furthermore, important gender differences exist in many societies con-cerning the
perceived advantages and disadvantages of having many children. Because women
disproportionately bear the costs of child-bearing and child-rearing, they are often more interested than men in limiting and
spacing births. Today, there are high levels of unmet need for family planning among
women in the developing world. Unmet need is a measure that represents the percentage
of women of reproductive age who wish to space or limit births but who are not
currently using a contraceptive method.
The Program of Action that emerged from the 1994 International Conference on
Population and Development emphasized that organized family planning programs are
but one component of a broader strategy to stabilize population growth rates and
improve well-being. The other ingredients include improving women's status,
expanding reproductive health services, poverty alleviation, improving infant and child
health services, education of the girl child, and increasing male responsibility. Work on
all of these fronts together is likely to have a greater impact on fertility than would
investment in family planning alone.
|
Case Example 2.7: Linking population and environment in south-west Uganda
The Kigezi region of south-western Uganda is a beautiful area characterized by heavily
terraced hills that quilt the landscape. Once covered by forest that extended from Zaire
to Burundi, most of the trees have been cleared for timber, building poles and arable
land. Only two major remnants of the forest remain intact in Uganda, and both were
designated as national parks by the government in 1992: Bwindi Impenetrable National
Park (BINP) and Mgahinga Gorilla National Park (MGNP). Together, the two parks are
home to over half of the world's population of mountain gorillas (Gorilla gorilla
berengei).
Beginning in 1986, NGOs have supported conservation and development activities
through agroforestry extension programs combined with conservation education and
community outreach. In 1994, a more participatory, need-driven approach was adopted.
The new activities include a ground-breaking multiple-use program in which certain
resource users from a community are allowed access to previously restricted forest
products, such as weaving materials and medicinal herbs.
In 1992, in part as a response to a desire for family planning assistance expressed by
community members and relayed through project staff, one of such NGOs (CARE)
initiated a region-wide family planning program. The Community Reproductive Health
Project (CREHP) works with the district health teams to train clinic personnel in the
delivery of family planning services in 74 regional health units. In 1994, CREHP began
selecting and training community volunteers to provide family planning counseling and
referral in their communities and to distribute contraceptives.
From the initial impetus for CREHP, the linkages between the two regional projects
were apparent. Population densities surrounding the parks are some of the highest in
Africa, exceeding 250 persons per square kilometer. Land shortage due to
overpopulation is one of the most pressing problems for people of the area, as reported
in numerous community surveys. Furthermore, there are serious doubts that the
conservation program will be sustainable if the local population continues to grow at its
current rate of about 3 percent. Finally, the desire for family planning among local
populations is high, due mostly to an inability to adequately provide for current children
and a pervasive lack of male support in the household.
From: Lindblade, 1994
|
Health status and quality of life
Decreased mortality (especially among infants and children) and a related increase in
life expectancy are evidence of a general improvement in the health status of human
populations. This phenomenon, which is in contrast to the sometimes apocalyptic news
and images of poverty, disease, malnutrition and death spread by the media, has
intrigued demographers and epidemiologists and incited them to ask: "Why is mortality
decreasing?"
Table 2.3: Some indicators of health status and quality of life at the local level
|
Topic | Indicators |
| Reproductive health |
average age at marriage, by gender;
average age at first and last birth;
average number of deliveries in women's reproductive life;
average length of child spacing, i.e., average duration of intervals between consecutive births to the same woman;
percentage of women who wish to delay childbearing or stop having children
who are not currently using modern contraception (unmet need);
percentage of women of reproductive age with access (walking distance, reasonable hours, manageable costs) to health care and family planning
services;
percentage of pregnant women without anemia;
percentage of deliveries with trained attendant at the birth;
percentage of pregnant women under age 25 who test negative for syphilis or
HIV/AIDS infection. |
| Mortality and morbidity (conventional health status indicators) |
mortality rates (infant, child, maternal);
top five causes of morbidity and mortality by age group (infants, under-5s, adolescents 10-19 and adults);
rates of diarrhea or acute respiratory infection in children under 5;
incidence of vaccine-preventable diseases (i.e., whooping cough, measles and
poliomyelitis) in children under 5;
prevalence of TB in different age groups;
prevalence of malnutrition in 1-5-year-old children;
prevalence of anemia in pregnant women;
incidence or prevalence of endemic diseases (such as malaria, schistosomiasis,
guinea worm, leishmaniasis, leprosy, etc.) in different age groups;
prevalence of alcoholism and drug addiction (by age and gender);
accidental death rate (by age group and gender);
rates of intentional deaths by age and gender (homicide, suicide). |
| Sustainable natural resources use |
percentage of arable land exploited;
percentage of land showing signs of degradation;
percentage of forested area lost or regained annually;
percentage of natural wetlands lost or regained annually;
depth of permanent water table (time trends);
number of endemic species of animals or plants that are extinct or endangered;
number, extent and danger of chemicals being used locally for pest or weed
control.
|
| Satisfaction of some basic needs |
percentage of children with basic anthropometric (nutrition and growth)
measures within accepted standard;
percentage of new-born babies with a birth weight within accepted standard;
percentage of households with access to safe water throughout
entire year;
liters per person of safe water available/in use;
percentage of houses properly protected against extreme weather;
percentage of households with a kitchen separated from the living area;
percentage of households with separate bedroom for every two persons;
percentage of households with income above the official poverty line;
percentage of households with savings or access to an equitable credit system;
labor division by age and gender within household;
male and female literacy rate;
percentage of children 6-12 years old enrolled in school;
percentage of 1-2-year-old children fully immunized against vaccine-preventable diseases;
percentage of households living within two hours of the nearest health unit (and
services provided at the unit);
average cost of services at nearest health unit (is it affordable by the ones most in need?);
percentage of adults actively participating in community
decision-making, by gender.
|
A study carried out by Caldwell (1989 and 1993) on a sample of 15 developing
countries showed that a strong correlation exists between health success (measured in
terms of mortality decrease and life expectancy increase) and the educational levels of
women of maternal age, followed closely by the practice of family planning and the
education of men, and to a lesser extent by the density of doctors and levels of nutrition.
Per capita income seemed to have little effect.
Based on these and other similar data, Murray and Chen (1993) suggested that
improvement in health status is related to two types of health promotive assets:
- physical assets, including health-care infrastructure, schools, transportation
facilities, housing, water supply and sanitation; and
- social assets, including education and health-related perceptions and behaviors.
|
Box 2.6: Ethical dilemmas
The reduction of human death rates has always been seen as an absolute good in public
health, and unease about population increase has never been an accepted constraint of
any public health measure. Will visions of the ultimate effects of population expansion
alter this view?
Hill (1960) called it "the most solemn problem of the world" and wrote: "If ethical
principles deny our right to do evil in order that good may come, are we justified in
doing good when the foresee-able consequence is evil?" In other words, are there some
programs which, although technically feasible, should not be initiated because of their
long-term population-increasing consequences?
In Preston's words (1978) should one deliberately "set levels of mortality control"? Is
what is done corporately in public health ethically different from what is done
individually? How far is it necessary to look into the future to decide between
immediate and distant goals? How much should ecological sustainability influence
health programs?
From: King, 1990
|
According to these authors, the summative effect of physical and social health assets
(which have developed, to a variable extent, throughout the world in the last 20 years)
should be considered as the leading cause of recent mortality decreases in the
developing world.
Meanwhile, the example from Ghana (see Chapter 1, Case Example 1.1) shows that
mortality and morbidity rates alone are not appropriate for describing the health status
of a community. The definition of health as comprehensive well-being requires that
health status be assessed not only in terms of decrease in mortality and morbidity, but
also with respect to quality of life. This raises some ethical dilemmas (see Box 2.6).
King has suggested re-defining health as a sustainable state of well-being. This state can
be achieved and maintained by keeping both population and consumption within the
limits set by the carrying capacity of local environment. Public health interventions
could thus be improved by including efforts aimed at limiting both population growth
and the exploitation of the natural resource-base.
In addition to considering the ethical dilemmas which population management and
health promotion situations pose, as pointed out by King (1990), the conventional
definitions of health are incomplete. Health equated to "absence of disease" or defined
in Primary Health Care as "complete physical, mental and social well-being" (WHO,
1978) does not include one fundamental aspect: that the health of a human community
is directly linked with the health of its natural and social environment.
Together with conventional 'negative' health status indicators such as mortality and
morbidity rates, positive indicators of health (i.e., of quality of life) could thus be
examined, focusing on issues such as reproductive health, sustainable use of natural
resources and satisfaction of basic needs.
A non-comprehensive example of a list of indicators for assessing health status and quality of life at the local level is provided in Table 2.3 (above).
| |