by FRANK W. NOTESTEIN
MANKIND has the technical ability to reduce the toll of sickness and poverty throughout the world to an extent never dreamed of even a few decades ago. Yet we teeter on the brink of self-destruction by allowing population growth to outstrip economic advance.
Both in the modernized countries and in the underdeveloped areas themselves there is much discussion, debate, and controversy over the population problem, but little action has been taken. Part of the controversy arises from honest and probably inevitable differences in moral judgments. But a larger part arises from misunderstandings both here and in the areas involved.
The problem is most intense in those parts of the world where average incomes are barely above the minimum of subsistence, illiteracy is prevalent, the traditional agrarian economy is largely intact, and scant use is made of modern technology in either industry or agriculture. The area, encompassing over a billion people, includes all of nonSoviet Asia except Japan, the South Sea Islands, all of Africa north of the Union, and virtually all of Latin America except Argentina.
Throughout most of these regions the tempo of population growth is mounting rapidly because death rates are falling while the birth rates remain at very high levels. On the average, the population may be growing by as much as 2 per cent per year, which, if continued, would double the present size of population in thirty-five years. In Mexico and several other Latin American countries, in the Philippines, Taiwan, and possibly Egypt, the population is growing at the rate of more than 3 per cent per year, which means that it would be double its present size in twenty-three years.
Populations that grow rapidly must also expand their economic production rapidly. When populations grow at the rate of 2 or 3 per cent per year, only that part of the country’s expanded economic production which runs above 2 or 3 per cent can be used for the improvement of living conditions. Such gains are difficult to obtain. True, in the United States during the past century, our economic production probably rose by 3 or 4 per cent per year. However, we had a vast, empty, and rich country, much foreign capital, and a relatively well-educated population.
The underdeveloped countries, by contrast, are frequently densely settled, often more than seven times as densely settled as we are now. Because available new land is scarce, the expansion of economic production is particularly dependent on technological innovations requiring capital. But foreign capital is scarce, and incomes are so low that savings are small.
No one knows exactly how much new capital is necessary to produce a given expansion of income, but it is safe to assume that populations growing at between 2 and 3 per cent per year must save and invest between 5 and 15 per cent of their annual incomes just to keep even. Any improvement in economic conditions must come from savings above these figures. Our own savings have been substantially higher, but it is easy to accumulate savings in a prosperous economy. The implications are entirely different for the poor economy, whose population frequently spends over 60 per cent of its income on food alone and remains seriously undernourished.
Higher levels of savings can be and have been forced in Russia and possibly in China. Grain has been sold on the world market to purchase industrial materials during a domestic famine. But such action does not represent an acceptable solution to the problem. There are many brutal ways of checking population growth, but we must find those that are acceptable in humanitarian terms, those that we would advocate if our own lives and those of our children were involved.
There is a further difficulty connected with population growth. Because of their very high birth rates, the populations of the underdeveloped countries are heavily concentrated in the ages below the working years of life. Most underdeveloped countries have more than 40 per cent of their total population under age fifteen. By contrast, the developed countries seldom have as much as 30 per cent. This burden of youth dependency is a heavy one. But in spite of the small proportions in the working ages, there is a great deal of underemployment. This ineffective use of the labor force only documents the economic difficulty inherent in the shortage of land and capital. Such shortages are, as we have seen, greatly intensified by population growth.
The conclusion is inescapable that rapid population growth lifts the rate of economic growth required to improve living conditions and at the same time, by expanding consumer needs, restricts the accumulation of capital that is essential for the technological innovations needed to attain such economic growth.
The cause of the rapidly mounting rates of population growth is clear. It is the spectacular reduction of the death rate made possible by the medical discoveries of the past three decades. The use of sulfa drugs, antibiotics, and insecticides such as DDT has permitted the control of infectious diseases on a scale and with a speed hitherto impossible. Death rates in many of the underdeveloped countries are declining three to five times as fast as they did in nineteenth-century Europe. Ceylon, for example, cut its death rate in half in ten years. Ceylon, Taiwan, Singapore, and a number of Latin American countries have death rates that are much the same as those of the modernized West — approximately 10 per 1000 population per year. The low rates come partly from rapidly mounting life expectancies. But they come also from the rapid growth yielded by high birth rates, which tends to concentrate the populations in the young ages, where the risks of death are rather low.
In most of the regions with which we are dealing, death rates are much higher than 10. Even so, progress has been made. No one knows the exact pre-war death rates of India and China, but they were probably a little above 30 during the good years and much higher during years of major epidemic. Now they are probably in the low 20s. Moreover, there is no reason why they should not continue to fall rapidly in response to the expanding public health programs of both countries. In still other areas, notably those of Central Africa, less progress has been made, but there, too, death rates will drop as soon as modern public health programs can be introduced.
It is important to note that this control of disease has been achieved by methods that depend little on the cooperation of individual members of the population. Crews spray homes and vaccinate and inoculate assembled villagers. Even treatment of the individual by sulfa drugs and antibiotics is brief, convenient, and inexpensive. In short, populations that in any case are rather willing to cooperate with efforts to improve their health have little cooperating to do. Health is almost brought to them. The new methods of controlling disease have another result. We have now learned how to keep death rates amazingly low even under conditions of appalling poverty.
Meanwhile, nearly all underdeveloped countries have more than 40 births a year for each 1000 population. A few report lower figures, but in such cases the registration of births can be shown to be incomplete. Birth rates above 45 are not at all unusual, particularly in Latin America and the Middle East. With modern death rates, the implication of such birth rates for growth is clear.
AGAINST this background, let us review briefly some of the misunderstandings that are prevalent here and abroad.
One is that if the birth rates are reduced, populations will decline. But if efforts in the field of public health are at all adequate, the birth rates of the underdeveloped areas could fall to less than half of their present level and there would still be moderately rapid population growth. In the absence of barbarities such as compulsory mass sterilization, as much as a 50-per-cent reduction of the birth rate seems outside the bounds of possibility in the foreseeable future. Given public order, the maximum reasonable objective is that of reducing birth rates sufficiently to hold the growth of population well below the expansion of the economy.
Extremists occasionally say that the West is interested in reducing the birth rates of underdeveloped countries as a substitute for economic development. The view is well publicized by Communist propaganda. Nothing could be further from the truth. Increased production must underlie any solution to the problems of poverty. The real danger is that they cannot be solved even with economic development unless there is some check on population growth. The hope of those seeking to reduce birth rates is not to find a substitute for economic development but a means of increasing the speed with which economic development can provide better living conditions for the population. The danger is that it will only provide more people living in much the same state of poverty.
We have every reason to suppose that it is virtually impossible to change the reproductive behavior of the traditional peasant society by a further intensification of its poverty. In a time when popular aspirations for health and prosperity are rising throughout the world, policies of repression are much more likely to bring revolution, disorganization, and mounting death rates than to stimulate the spread of the small-family ideal.
There is also the completely opposite view, which holds that only economic development is required. The advocates of this position point to the fact that birth rates have fallen in the context of urban-industrial development and popular education in the Western world. We should, they say, forget about population growth entirely and concentrate on urban-industrial development, public education, health, and improving the status of women.
This view receives support from some individuals who are opposed to various methods of birth control on moral grounds and seem to think they can escape from the difficulty of accepting contraception by advocating urban-industrial development. But there is compelling evidence that whenever the forces of modernization have developed the incentive for birth restriction, the restriction itself has been accomplished mainly by the spread of contraceptive practice. Notwithstanding claims to the contrary, reductions in fertility have been achieved overwhelmingly through voluntary means, by not marrying, or by preventing conception, or by interfering with the survival of the fetus. People opposed to birth control would be in a more tenable position if they opposed economic development and education on the grounds that such innovations were likely to stimulate the spread of contraception.
The thesis that birth rates will decline in the presence of economic development says nothing about the speed with which a downward trend of fertility may be expected to get underway or about the number of times the population would double before birth rates and death rates came into fairly close balance. In Japan, where there has been rapid modernization since the 1860s, the population has increased threefold and the rate of growth is still substantial, in spite of the fact that it now has the lowest fertility in the world. The multiplication encountered during the transition from high to low birth and death rates was even larger in the West. There are grounds for doubting that the automatic processes of social change will bring a sufficiently rapid adjustment. Today, the fertility of married women is much the same in the major cities of India as in the rural villages, and the same lack of contrast probably prevails in many other countries.
FINALLY, there is the group, to which the writer belongs, that is convinced of the importance of taking energetic measures to spread the practice of birth control. The group is large and growing very rapidly in several of the underdeveloped countries. This was amply demonstrated last winter in New Delhi at the International Conference on Planned Parenthood, which was opened by Prime Minister Nehru and participated in by many leaders of academic, medical, and public life, drawn from a wide variety of underdeveloped countries as well as from the West.
There is mounting interest in stimulating the decline of the birth rate by spreading contraceptive practice, but in view of the dimensions of the problem only the smallest start has been made. There are grave difficulties and wide divergencies of opinion as to the proper course to take. Much of the disagreement comes from the fact that no effort to promote restrictive practices in the peasant villages has yet proved very successful. Too few attempts have been made to test inexpensive but sophisticated programs.
Admittedly, it is difficult to use existing contraceptive methods under the conditions of the usual peasant home, which lacks privacy, sanitary facilities, and suitable storage places. Neither is the situation favorable for the practice of periodic abstinence. Frequent confinements and a heavy incidence of infection, anemia, and malnutrition interfere with the establishment of predictably regular menstrual cycles. Moreover, the level of education is so low that many women find it impossible to keep track of their calendars. Ingenuity has been used to assist them. In one experiment, a string of green and red glass beads was supplied to each woman with instructions that she should move one bead along each day, abstaining on the “red days.” A few were used appropriately, but in more cases there were accidental mix-ups or the beads served either as jewelry or as playthings for the baby. One patient is reported to have said that the beads were very good but that her husband steadfastly refused to eat them.
Such difficulties have led some people to conclude that success is impossible until we have developed a contraceptive method that is effective, convenient, cheap, and safe even under conditions of gross misuse. It is this need that has stimulated the interest in research for a contraceptive tablet to be taken by mouth.
Unquestionably, there is great need for research to find better methods of fertility control and to enhance all aspects of our knowledge of human reproduction. Until recently, pathetically little was being done. Now hopes are high that within something like five years we shall have several greatly improved methods.
Many people seem to think that the problem would be solved as soon as we could match, on the side of fertility, the scientific advances with which we control mortality. Unfortunately, this conclusion overlooks the fundamental differences between mortality and fertility. No one wants to die. But many people want large families. To still more, the idea of not accepting happily the number of children that “ God sends” has never occurred and, when proposed, is likely to be abhorrent. Throughout the ages of inevitably high mortality, the selective processes of survival have placed a high value on those societies that inculcated the desire for many births. The rewards and penalties of family and community life in matters of security and prestige are heavily oriented in favor of the parents of many children, particularly of many sons. These ideas have been deeply imbedded for centuries in the most fundamental institutions and beliefs and are difficult to change.
Technological efficiency in fertility control will be an invaluable assistance to couples who are hesitant, frightened, and weakly motivated toward restricting the number of their births. But new and efficient methods will have their major impact only as the older ideals concerning appropriate reproduction are replaced by a widespread and deeply felt awareness of the advantages of fewer births. In sharp contrast to the problem of reducing births, the basic problem in the control of fertility is that of moving men’s minds. In free societies, the choices governing procreation must ultimately remain those of individual couples.
There is a wide range of positive action open to us. In the first place, we need to foster a better understanding of the relations of population growth to health, education, and prosperity among the articulate and politically active elements of the regions concerned. Often, as in India, Pakistan, Egypt, and Ceylon, this understanding is already present at the highest levels of government. But a more broadly based understanding is needed to provide political support for programs of the required scope. In all too many areas there is little interest or understanding, even at the highest levels.
It is unlikely that we in the West can do much to promote this understanding directly. Our opinions are viewed with too much suspicion to have a maximum effect. One of the most useful things we can do is to train students from underdeveloped areas to study their own problems by modern scientific methods. The findings of their own specialists, lucidly interpreted to the public, will carry much more weight than anything we can say.
In this field of scientific training, a good beginning has been made by the United Nations, governmental exchange programs, and the work of private foundations. Two regional centers for demographic training and research have been started under the auspices of the United Nations, one in India and one in Chile. In addition, fellowship programs are bringing students to the West for training. At Princeton, for example, students have come for advanced training in population research from eighteen different countries. These students have already done much to broaden the understanding of the issues in their own countries. The research of the United Nations has also been valuable in helping governments determine the facts for themselves.
Widespread knowledge of population problems only helps gain public support for needed action. Changes in individual behavior come for private reasons, such as the realization by married couples that, under modern conditions of health, their family life will be enriched if there are fewer births. We must learn how to impart this understanding efficiently, but the work itself is so peculiarly sensitive that it had better be undertaken by indigenous agencies. At least at the present stage, our role might well be limited to supplying requested assistance in technical training, consultation, and experimental work. These tasks are far from small, and the needed work is scarcely begun.