Population and Development — Shifting Paradigms, Setting Goals
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《新英格兰医药杂志》
At the first United Nations–sponsored international conference on population — held in Bucharest, Romania, in 1974 — the United States and other Western nations advocated the implementation of programs aimed at controlling the high rates of population growth then prevalent in resource-poor countries in Africa, Asia, and Latin America. Most leaders from these countries, however, saw this as an inappropriate, imperialist goal to be imposed on their countries, when the real problems were related to poverty. Ten years later, at the second international conference in Mexico City, representatives of the Reagan administration argued that population growth was not a key issue and that, instead, the expansion of free-market systems was the key to development in poor countries. But by that time, many leaders of developing countries had reached the opposite conclusion — namely, that high rates of population growth were indeed hindering both economic and social development. At the meeting, there was also much debate about abortion-related issues, with the U.S. government and the Vatican highlighting an antichoice agenda.
A decade ago, the 1994 Cairo International Conference on Population and Development (ICPD), the third in the series, marked a paradigm shift in the way the international community approached population issues. A 1994 study, analyzing demographic and health surveys carried out repeatedly in many developing countries over the previous 10 to 15 years, demonstrated that there was a large unmet need for contraception and that simply meeting that need would allow countries with goals for slowing population growth to reach them.1
Strengthened by this information, and led by activists from a large number of nongovernmental women's groups, the ICPD shifted the focus of its agenda from demographic goals to a set of ambitious goals regarding reproductive and sexual health and rights, including attention to family planning, human immunodeficiency virus infection and other sexually transmitted infections, and maternal mortality, with a special emphasis on the empowerment of women. The U.S. government, along with other governments, made a substantial financial commitment to the ICPD program of action.
Unfortunately, only months after the 1994 conference, a change in the political balance of the U.S. Congress led the United States to withdraw from its leadership position with regard to this ambitious agenda and to renege on the fiscal targets that had been set — a situation that continues to the present. As a result, in the 10 years since that conference, insufficient funding has meant that millions of people still do not have access to contraceptive services, high maternal mortality rates remain essentially unchanged, many women still die from complications of unsafe abortions, and other goals have been similarly neglected.
Despite these setbacks, the situation today is very different from that in the late 1960s. At that time, the rate of global population growth reached a historic high of approximately 2 percent per year, with a resultant population-doubling time of just 35 years.2 In a few resource-poor countries in Asia, Africa, and Latin America, growth rates were as high as 3.5 percent, and the prevalence of contraceptive use was extremely low, generally estimated at 5 percent or lower. By the early 1990s, a remarkable change had occurred, leading some to suggest that the population and family-planning programs in resource-poor countries, which had been initiated in the late 1960s, constituted one of the most important public health success stories of the second half of the 20th century (see table).
Projected Population Growth.
Today, modern contraceptive methods are being used by about half of married women in less developed countries, and the rate of population growth in the developing world has dropped to an estimated 1.5 percent.3 This increase in the use of contraception has contributed substantially to a decrease in the average number of births per woman (see graph). Thailand provides a clear example of a country that expanded the availability of contraception and experienced a resulting decline in fertility. In the early 1960s, less than 5 percent of couples in Thailand were using contraception.4 The expansion of access to modern contraceptive methods through voluntary programs allowed the proportion to reach 70 percent by 2004 — a figure on a par with those in developed countries.3
Number of Births per Woman in 1980 and 2001 in the 10 Countries with the Highest Birth Rates in 1980.
Data are from the Development Data Group of the World Bank.
Although countries such as Thailand have reaped the benefits of increased access to family-planning services, the unmet need remains high in most of sub-Saharan Africa and South Asia. The prevalence of contraceptive use in these regions remains low, and there continue to be high rates of population growth, despite the effect of the AIDS pandemic in some of these countries. In sub-Saharan Africa, only an estimated 14 percent of married women are using a modern birth-control method. That rate is substantially lower in many countries on the African continent, such as Nigeria, where only 8 percent of women use modern methods, and Ethiopia, where some 6 percent use such birth control.3 The total population of the 49 least developed countries is projected to more than double, reaching almost 1.7 billion by 2050.5 Nonetheless, the evidence is growing that some of the poorest countries are beginning to make the transition to smaller families.
(Figure)
Mobile Health and Family Planning Clinic, Udaka, India.
Robert Nickelsberg/Time Life Pictures/Getty Images.
Whereas the past decade has been disappointing in terms of the broad goals of the ICPD program of action, the more recent focus on Millennium Development Goals holds much promise. Initially, for political reasons, sexual and reproductive health and rights were not explicitly included in these goals. But the United Nations Millennium Project, whose director reports to the U.N. secretary-general, made a commitment, in its draft final report outlining a global plan for meeting the Millennium Development Goals, to address most of the objectives of the Cairo meeting, including equity between the sexes and the empowerment of women. The World Bank and the World Health Organization have also recognized that the sexual and reproductive health and rights articulated in the ICPD program will be essential elements of any effective strategy for meeting the development goals. In addition to fulfilling the needs identified at Cairo, serious new efforts are required to reduce maternal mortality, to deal with the AIDS pandemic and its particularly heavy toll on women in poor countries, and more generally, to reduce poverty in resource-poor countries. The achievement of these aims, like the reaching of the goals enunciated years ago by many committed to slowing population growth, will improve the social and economic welfare of people in the resource-poor nations of the world.
Source Information
Dr. Rosenfield is the dean and Ms. Schwartz a graduate research assistant at the Mailman School of Public Health, Columbia University, New York.
References
Sinding SW, Ross JA, Rosenfield AG. Seeking common ground: unmet need and demographic goals. Intl Fam Plann Perspect 1994;20:23-7, 32.
The world at six billion. New York: United Nations, October 12, 1999. (Accessed January 28, 2005, at http://www.un.org/esa/population/publications/sixbillion/sixbillion.htm.)
2004 World population data sheet. Washington, D.C.: Population Reference Bureau, 2004. (Accessed January 28, 2005, at http://www.prb.org.)
Rosenfield AG, Bennett A, Varakamin S, Lauro D. Thailand's family planning program: an Asian success story. Intl Fam Plann Perspect 1982;8:43-51.
State of the world population report 2004. New York: United Nations Population Fund, September 15, 2004. (Accessed January 28, 2005, at http://www.unfpa.org/about/index.htm.)(Allan Rosenfield, M.D., a)
A decade ago, the 1994 Cairo International Conference on Population and Development (ICPD), the third in the series, marked a paradigm shift in the way the international community approached population issues. A 1994 study, analyzing demographic and health surveys carried out repeatedly in many developing countries over the previous 10 to 15 years, demonstrated that there was a large unmet need for contraception and that simply meeting that need would allow countries with goals for slowing population growth to reach them.1
Strengthened by this information, and led by activists from a large number of nongovernmental women's groups, the ICPD shifted the focus of its agenda from demographic goals to a set of ambitious goals regarding reproductive and sexual health and rights, including attention to family planning, human immunodeficiency virus infection and other sexually transmitted infections, and maternal mortality, with a special emphasis on the empowerment of women. The U.S. government, along with other governments, made a substantial financial commitment to the ICPD program of action.
Unfortunately, only months after the 1994 conference, a change in the political balance of the U.S. Congress led the United States to withdraw from its leadership position with regard to this ambitious agenda and to renege on the fiscal targets that had been set — a situation that continues to the present. As a result, in the 10 years since that conference, insufficient funding has meant that millions of people still do not have access to contraceptive services, high maternal mortality rates remain essentially unchanged, many women still die from complications of unsafe abortions, and other goals have been similarly neglected.
Despite these setbacks, the situation today is very different from that in the late 1960s. At that time, the rate of global population growth reached a historic high of approximately 2 percent per year, with a resultant population-doubling time of just 35 years.2 In a few resource-poor countries in Asia, Africa, and Latin America, growth rates were as high as 3.5 percent, and the prevalence of contraceptive use was extremely low, generally estimated at 5 percent or lower. By the early 1990s, a remarkable change had occurred, leading some to suggest that the population and family-planning programs in resource-poor countries, which had been initiated in the late 1960s, constituted one of the most important public health success stories of the second half of the 20th century (see table).
Projected Population Growth.
Today, modern contraceptive methods are being used by about half of married women in less developed countries, and the rate of population growth in the developing world has dropped to an estimated 1.5 percent.3 This increase in the use of contraception has contributed substantially to a decrease in the average number of births per woman (see graph). Thailand provides a clear example of a country that expanded the availability of contraception and experienced a resulting decline in fertility. In the early 1960s, less than 5 percent of couples in Thailand were using contraception.4 The expansion of access to modern contraceptive methods through voluntary programs allowed the proportion to reach 70 percent by 2004 — a figure on a par with those in developed countries.3
Number of Births per Woman in 1980 and 2001 in the 10 Countries with the Highest Birth Rates in 1980.
Data are from the Development Data Group of the World Bank.
Although countries such as Thailand have reaped the benefits of increased access to family-planning services, the unmet need remains high in most of sub-Saharan Africa and South Asia. The prevalence of contraceptive use in these regions remains low, and there continue to be high rates of population growth, despite the effect of the AIDS pandemic in some of these countries. In sub-Saharan Africa, only an estimated 14 percent of married women are using a modern birth-control method. That rate is substantially lower in many countries on the African continent, such as Nigeria, where only 8 percent of women use modern methods, and Ethiopia, where some 6 percent use such birth control.3 The total population of the 49 least developed countries is projected to more than double, reaching almost 1.7 billion by 2050.5 Nonetheless, the evidence is growing that some of the poorest countries are beginning to make the transition to smaller families.
(Figure)
Mobile Health and Family Planning Clinic, Udaka, India.
Robert Nickelsberg/Time Life Pictures/Getty Images.
Whereas the past decade has been disappointing in terms of the broad goals of the ICPD program of action, the more recent focus on Millennium Development Goals holds much promise. Initially, for political reasons, sexual and reproductive health and rights were not explicitly included in these goals. But the United Nations Millennium Project, whose director reports to the U.N. secretary-general, made a commitment, in its draft final report outlining a global plan for meeting the Millennium Development Goals, to address most of the objectives of the Cairo meeting, including equity between the sexes and the empowerment of women. The World Bank and the World Health Organization have also recognized that the sexual and reproductive health and rights articulated in the ICPD program will be essential elements of any effective strategy for meeting the development goals. In addition to fulfilling the needs identified at Cairo, serious new efforts are required to reduce maternal mortality, to deal with the AIDS pandemic and its particularly heavy toll on women in poor countries, and more generally, to reduce poverty in resource-poor countries. The achievement of these aims, like the reaching of the goals enunciated years ago by many committed to slowing population growth, will improve the social and economic welfare of people in the resource-poor nations of the world.
Source Information
Dr. Rosenfield is the dean and Ms. Schwartz a graduate research assistant at the Mailman School of Public Health, Columbia University, New York.
References
Sinding SW, Ross JA, Rosenfield AG. Seeking common ground: unmet need and demographic goals. Intl Fam Plann Perspect 1994;20:23-7, 32.
The world at six billion. New York: United Nations, October 12, 1999. (Accessed January 28, 2005, at http://www.un.org/esa/population/publications/sixbillion/sixbillion.htm.)
2004 World population data sheet. Washington, D.C.: Population Reference Bureau, 2004. (Accessed January 28, 2005, at http://www.prb.org.)
Rosenfield AG, Bennett A, Varakamin S, Lauro D. Thailand's family planning program: an Asian success story. Intl Fam Plann Perspect 1982;8:43-51.
State of the world population report 2004. New York: United Nations Population Fund, September 15, 2004. (Accessed January 28, 2005, at http://www.unfpa.org/about/index.htm.)(Allan Rosenfield, M.D., a)