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# Global health cannot be achieved without efforts to curb population growth

BMJ 2011; 343 (Published 31 October 2011) Cite this as: BMJ 2011;343:d7003
1. Robin Stott, co-chair, Climate and Health Council
1. stott{at}dircon.co.uk

Population stabilisation is essential to healthy societies, and is fortunately an inevitable outcome of the evolution of such societies. My line of argument is to understand what underlies healthy societies, and to provide evidence that non-coercive population stabilisation is a key and attainable attribute of such societies.

Over the past 150 years health professionals have, with increasing clarity, defined the characteristics of a healthy society. Michael Marmot’s recent report to WHO1 articulated the determinants of health and set out how the circumstances in which we are born, grow, live, work, and age are best arranged to ensure that people are likely to be healthy. In essence, the social, economic, and environmental determinants of health need to be so arranged that basic human needs are met, the available resources are shared more rather than less equally, and resources are delivered without overusing the limited environmental goods available to us. A “fair shares” society is a convenient shorthand way of describing such health promoting arrangements. Wilkinson and Pickett, in The Spirit Level,2 provide compelling further evidence for the health benefits of such fair shares societies.

There are no universally agreed indicators to mark countries that have attained this happy state. The UN based Human Development Index (HDI), which is a comparative index of life expectancy, literacy, education, and standards of living, is as good as we can presently get. Although it did not take inequalities between the sexes into account until recently, and has no marker of per capita resource consumption, it does indicate that where female education is combined with appropriate resources to allow access for all to family planning, fertility rates fall, often to below replacement values (that is, the level of fertility at which a population exactly replaces itself from one generation to the next). The HDI thus reflects the extensive evidence showing that female education and access to resources is the key to achieving a stable, and indeed often reducing, population. Reduced maternal morbidity (through reduction in infections, unsafe abortions, and obstructed labour) and a reduction in infant mortality are associated benefits, and provide the supportive framework within which smaller families become the norm.

The relation between HDI and fertility rate is nearly linear; an improving HDI, and so health status, is unequivocally related to a decline in fertility, often to below replacement levels.3 Because of childhood mortality, and the increasing number of women who do not wish to have children, the replacement fertility rate at which the global population would remain constant at around nine billion people by 2050 is presently 2.33.

The improvement in the HDI, and so the non-coercive demographic transition to a stable or decreasing population, can be very rapid, as exemplified by Iran. In 1986, Iranian women were having seven children each on average; only 40% of women enjoyed secondary education, and the corrected HDI was 0.493. By 2008, female enrolment in secondary education was 80%, the HDI 0.702, and the fertility rate below replacement at 1.8.4 The dramatic rise in female literacy coupled with access to family planning services is again a common theme in countries with low fertility rates. How easy will it be to achieve these two outcomes? The UN estimates that 215 million women who do not want to become pregnant have no access to contraception. This could be resolved by allocating a further $3.5bn (£2bn; €2.5bn) per year to these services.5 More than 100 million children get no schooling6 and more than half of these are girls. According to Action Aid, commitment of an extra$10bn a year would resolve this problem. These are small sums of money, and what is lacking is the political courage and will, both in countries that suffer from poor health and—more importantly—in the global community.

We know that population stabilisation is essential for good health, we know what works to achieve it, and the resources required can be obtained through small changes in our globalised economy. Moving to curb population and so stabilise the global population is essential, relatively straightforward, and not expensive.

Population stabilisation is also helpful in tackling climate change, as clearly more people will consume more resources. But here there is a more complex issue.

The HDI doesn’t reflect the unsustainable use of resources, which is a persistent feature in all developed countries with high HDIs, with the single exception of Cuba. To effectively tackle climate change our global society needs to curb this overuse of resources. Although we know theoretically and practically how to curb population, we have no current examples of societies voluntarily reducing consumption. If we take average carbon dioxide emissions as a marker of consumption, the countries with high HDI and low fertility emit more than 10 tonnes per person per year, and those with low HDI and high fertility around 1.5 tonnes per person per year. For a population of 9 billion the sustainable amount is a maximum of 1.5 tonnes. Reducing our unsustainable with its associated carbon emissions—which, to achieve a fair shares healthy society, has to be done in synergy with the necessary transfer of resources—is the truly formidable issue of our times. Many health professionals advocate implementation of the global framework of contraction (reducing global carbon emissions to sustainable limits) and convergence (a rapid but negotiable move to equal entitlements of this scientifically assessed residual carbon). This framework, which is widely supported (www.gci.org.uk), will greatly facilitate the evolution of the low carbon, fair shares society that is essential to health. Vigorous advocacy from health professionals, acting in concert with many others who support this framework, and coupled with patient negotiation and perseverance, will be needed to put it in place; stabilising populations is, by comparison, straightforward.

## Notes

Cite this as: BMJ 2011;343:d7003

## Footnotes

• Competing interests: RS is co-chair of the Climate and Health Council, an organisation that seeks to mobilise health professionals to become actively engaged in tackling climate change.

• Provenance and peer review: Commissioned, not externally peer reviewed.

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