Kerala's Demographic Transition: Determinants and Consequences

BMJ 1999; 318 doi: (Published 26 June 1999) Cite this as: BMJ 1999;318:1771
  1. John A Black, retired consultant paediatrician
  1. Victoria Mill House, Framlingham, Woodbridge

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    K C Zachariah, S Irudaya Rajan

    Sage Publications, £29.99, pp 367

    ISBN 0 8039 9392 7

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    The achievement of demographic transition—with fertility at replacement level—by the south Indian state of Kerala, despite it being one of the poorest states in the country, has overturned the previous assumption that demographic transition could occur only in wealthy communities. This book covers the subject of Kerala's success in four sections:demographic transition, determinants of demographic change, consequences of demographic change, and migration.

    Two questions arise from Kerala's experience: first, can the state's policies be applied to other parts of India, and, second, can they be transplanted to other low income communities, notably in sub-Saharan Africa? The first question is answered in the affirmative, although the discussion is not as full as I would have liked, and the second question is not addressed at all.

    It is necessary to examine the factors that enabled Kerala to achieve its demographic targets. Until the development of road and rail links, Kerala was cut off from the rest of south India by the mountains of the Western Ghats and was influenced by its trade with Arabia, China, and, later, with Europe. Christianity was established long before the Portuguese arrived in the 16th century, and today Kerala has the largest proportion of Christians (20%) of any Indian state (2% in India as a whole). The Christian community, helped by missionaries, set up schools and hospitals and was xsupported by progressive rulers of Travancore and Cochin, which were amalgamated in 1956 to form the state of Kerala. From 1956 onwards there has been continuous expansion and development of the education and health services.

    The social structure of Kerala was uniquely favourable to the emancipation of women, influenced by the tradition of matrilineal inheritance practised by the powerful caste of Nayars. The combination of free primary and secondary education, introduced in the early part of the 20th century, with female emancipation, laid the foundations for high female literacy (75% in Kerala, 30% in India as a whole), which in turn determined the acceptance of free family planning services. But the precondition for this was low infant mortality, which, by 1993, had fallen to 17 deaths per 1000 live births (compared with 90/1000 in India). Thus, the order of events essential to achieving demographic transition was high female literacy, low infant mortality, low birth and fertility rates, and easily accessible free family planning services.

    Clearly, for historical reasons Kerala's experience cannot easily be replicated in other parts of India. One of the most telling tables (p 74) shows a time lag of about 20 years between the achievement of specific levels of fertility and infant mortality by India compared with Kerala. However, in the neighbouring state of Tamil Nadu fertility has almost reached replacement level in spite of a high level of female illiteracy. This has been achieved by a family planning programme integrated with maternal and child health services. What both states share is the political will to succeed, which does not seem to be present in some other Indian states.

    In spite of the depressing state of sub-Saharan Africa, Kerala's policies hold some lessons for the region. Currently, most of these states cannot afford a level of education and health services that would ensure demographic transition. African societies are pronatalist with a strong patriarchal tradition, and it is the husband who normally determines the desired number of children (although in one survey in Nigeria nearly a fifth of men and women replied that “god made the decision”). Until recently, family planning programmes have concentrated on women, and the failure to involve men is now seen as a mistake. Similarly, attempts to promote family planning in the face of high infant mortality are unlikely to succeed. Clearly, the key to improvement in sub-Saharan Africa lies in the reduction or, better, the cancellation of external debt repayment; this would enable adequate education and health services to be developed.

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