Category: Public Health

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Population Public Health

Age Gracefully—1-2014

Last July, when I turned 70, I wrote about my own aging. What happens as a large group of people age?

Let’s look at the start of the process of demographic change, when birthrates fall. This causes a decrease in the number of young people so there are fewer dependents. With more people in the working age range and not many old people yet, the group can prosper; this is the “demographic dividend”. Many regions have experienced this, notably in Africa and Asia. A European example will serve us better, however, since the information is more complete.

The Republic of Ireland is strongly Roman Catholic. In 1935 the government made contraception illegal, except for fertility awareness methods.  Their Total Fertility Rate (TFR—the average number of children a woman will bear during her lifetime) climbed to 4.  Despite its strong religious heritage, the country legalized contraception in 1979. Then TFR gradually dropped to about 2—below replacement and in the current range of other European countries. During the 1990s Ireland enjoyed a period of economic growth.

What is going to happen to countries as their populations age? Will it be as much of an detriment to economies as the demographic dividend was a benefit?

Never before have whole countries had their populations shrink voluntarily so markedly as is happening now. Perhaps the closest western civilization encountered was in Europe during the mid-14th century—the Black Death. This pandemic is estimated to have killed half of all Europeans. Indeed, the popular press has drawn the analogy of population shrinkage to a plague.

Half of the world’s countries have a TFR less than replacement—less than 2.1—which means they will decrease in population. This shrinkage has been slow at first, but birthrates seem to continue dropping. What some people fear is the change in the age structure. There will be an advantage because there will be fewer dependent young people. At the same time, people are living significantly longer than previously, so the number of older people will increase, increasing the number of dependents for each working person.

How can countries deal with this change in demographics? Will this transformation in age structure spell economic disaster? Some writers think so.

Perhaps the best glimpse into the future is the example of Japan, where one quarter of its population is 65 years old or older. It has the very low TFR of 1.4, little immigration and its population is shrinking at about 0.2 % annually. Furthermore, because of good diet and fine medical care, the life expectancy for a child born now is 83 years—about the best in the world.

How has the graying of its population affected the Japanese people? One trivia is the sale of diapers. They are unique in the world because sales of baby diapers will soon be by equaled by sales of adult diapers.

Birth control pills were not available in Japan until 1999. For many years people relied on just condoms and abortion to plan their families. Nevertheless, the TFR dropped below 2.0 in 1975. The sociological changes that have catalyzed this low reproductive rate include the changing role of women. Instead of staying home, now many women are well educated, work outside the home and postpone marriage until they are older.

Japan has avoided economic disaster despite the aging of its people, although they did suffer from the 2008 recession. The average retirement age is close to 70—since people are healthier, they can work longer. Because of the smaller number of children, there are still plenty of workers to support each dependent person.

Many European countries also have aging populations, but they use a different method to deal with the decreasing number of native young, low-skilled workers. They have “guest worker” programs, which allow people to immigrate from poorer countries to do work that the locals don’t want to perform.

Demographics are changing in many countries. In cultures that are aging, some occupations and businesses will have decreased demand, including obstetricians, childcare and teachers. Other occupations and businesses will increase—geriatricians, retirement communities and physical therapists.

The “population explosion” is not over. We are still growing by almost 80 million people yearly—mainly in poor, southern countries. Many people have enjoyed the demographic dividend, but the time has come to adjust to a new reality. Since growth cannot go on forever, it is absolutely necessary to reach a stable population, which means a period of population aging.

© Richard Grossman MD, 2014

Categories
Family Planning Population Public Health

Puerto Rico

This story started 30 years ago when we lived in Puerto Rico. Actually, the real beginning was 15 years before that, in Nicaragua.

We returned to Puerto Rico this spring after a three-decade absence. The island seemed even better than when we lived there. There was less trash, people were friendlier and now toll roads bypass overcrowded arteries.

Of course, Puerto Rico is not a separate country, but a commonwealth of the USA. Fortunately Puerto Rico keeps independent statistics, and one of them was a real surprise.

Flash back to 1968. My best experience in medical school was in the little Nicaraguan town of Puerto Cabezas, on the Caribbean coast. I learned a huge amount from the one physician, Ned Wallace, at the Moravian hospital there.

Gail (then my wife of only two years) and I lived in a tiny cabin with another medical student couple, a short walk to the hospital—and to the Caribbean Ocean. We adopted Noxa (“hello” in Miskito), a sociable green parrot.

We traveled by dugout canoe to provide the first medical care some villagers had ever received. Our wives passed out worm medicine and gave immunization shots, while we medical students saw patients in the four languages of the area—Miskito, Spanish, Creole and English. It was not the best medical care, but our patients were appreciative.

Ned was an excellent role model—he could do just about anything! I realized that living and practicing medicine in the tropics had personal advantages, in addition to helping people. At that time I resolved that, if we ever had kids, they should grow up knowing that the entire world was not like the USA, and that everyone didn’t speak English. Fortunately, Gail agreed.

In 1983 we moved our family from Durango to the little hill town of Castañer in central Puerto Rico. I practiced medicine and our two sons, in 3rd and 6th grades, learned Spanish by immersion. It was an enlightening experience in a different culture.

I was frustrated in Castañer by the number of women who wanted to limit their fertility, but lacked the money. Typically women married young and had 3, 4 or more closely spaced children. When I asked older women what birth control they used, the answer was often “my husband takes care of me” (withdrawal) or “I’ve been operated” (tubal ligation). Birth control pills and IUDs, effective temporary means of contraception, were just too expensive in this impoverished area.

Before returning to Puerto Rico this year I consulted the World Population Data Sheet (www.prb.org) for some demographic information. To my surprise the TFR (Total Fertility Rate—the number of children a woman has during her lifetime) was low. For a society to neither grow nor shrink, the TFR has to be about 2.1–one child to replace teach parent, plus a fraction for children who die before adulthood. Puerto Rico’s TFR is 1.6 now, far below replacement! However, it will take several decades for the population to stabilize.

What brought about this change In Puerto Rico? Did people recognize that the island is limited in size, that it has approached its carrying capacity? Is it that there is less adherence to religious doctrine?

Nobody seems to know exactly what happened. As far as I can make out, however, marriage is later and more couples choose to be childless. More women are employed, a common reason people choose smaller families.  The main change seems to be that contraception and tubal ligation (still very popular) are available with governmental aid, helping people achieve their reproductive and economic goals. Legal abortion is less common now that contraception is easier to obtain.

Puerto Ricans live in a beautiful green place of sun and ocean, but they have low incomes by our standards—only a third of the average income on the mainland. Thanks to government support, now people are able to receive the family planning services they desire. Puerto Rico has joined half of the world’s countries where women have sufficient access to family planning so that their populations will eventually stop growing. Where does the USA fit in? our TFR, at 1.9, is slightly below replacement.

Our return to Puerto Rico was lots of fun. We visited with friends and enjoyed the sun and ocean. Teaching our granddaughters to body surf was special for me. I also learned that even a poor area, if it has the will to help women control their fertility, can achieve zero population growth along with an improved economy.

© Richard Grossman MD, 2013