Population & Health

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2014 | 2015 edition

TOPIC EYE A-Level Geography

Population & Health

Population &Health 2014 l 2015 edition

1 OverviewChanges in population, threats to health, and developments in healthcare.

2 Dengue fever – the next global threat?Paul Guinness discusses the causes of dengue fever, its growing prevalence and how this disease can be addressed.

6 NCDs in the developing world David Redfern looks at the growing threat posed by non-communicable diseases (NCDs) throughout the world and, in particular, in developing countries.

10 Exploring the 2011 Census The census is a giant snapshot of the whole nation taken every 10 years. David Holmes examines the ideas behind the 2011 Census for England and Wales and describes the key outcomes in the context of the 2001 Census.

14 Healthcare provision in the UK and USAThe provision of healthcare in the UK and USA is undergoing a transformation. David Redfern considers the changes and why they have caused so much controversy.

18 The demographic dividend – a window of opportunity? Garrett Nagle explains the concept of the demographic dividend and assesses the prospects for sub-Saharan Africa.

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2014 | 2015 edition


Population & Health

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OverviewOne of the growing threats to people around the world is the increasing incidence of infectious diseases, some of which are being influenced by modern lifestyles. The recent measles outbreak in South Wales illustrates the constant challenge that such diseases present. Paul Guinness discusses the spread, causes and possible prevention of dengue fever – one of the emerging public health concerns around the world. It is clear that its spread owes much to the increasing levels of urbanisation, international travel and trade, and hence could be viewed as an unintended consequence of both development and globalisation.

As countries develop, from the outcomes of globalisation, the standard of living and lifestyles of the people in these countries also change. Non-communicable diseases (NCDs), such as cancer, obesity and heart disease, have previously been thought to be the preserve of the wealthy industrialised nations. However, this is changing. The risk factors – use of tobacco, overuse of alcohol, poor diet, etc. – are now as widespread in the developing world as they have been in the developed world. David Redfern reviews the social and economic effects of these conditions, which have their greatest impact in terms of increasing levels of morbidity but, of course, may ultimately lead to death.

Managing healthcare within a nation, especially in times of economic restraint, depends on accurate data from which strategic decisions can be taken. A key element of collecting such data is a census. David Holmes reviews the latest findings of the most recent census in 2011 for England and Wales, both in a national context and in some local contexts. More detail will emerge with time and you are advised to keep abreast of the information as it is published in the coming months. Censuses are a mine of information, as this article illustrates. One may wonder why some politicians question their purpose.

The role of politicians is never greater than in forming policies regarding the provision of national healthcare systems. Two leading industrialised nations – the UK and USA – have recently undertaken radical reform of their respective healthcare systems, and not without some considerable opposition. David Redfern reviews the changes that have taken place in each country and considers the reasons why they have resulted in such controversy. It is also interesting to note that these two sets of reforms have gone in the opposite directions politically: in the USA the system is considered by some to have become more socialist; in the UK the system is becoming more privatised.

One of the outcomes of falling birth and death rates around the world has been the creation, for a small number of decades only, of the ‘demographic dividend’. This is a period of time when there are significantly larger proportions of working adults within the population of a country. Countries such as Brazil, China and India have made use of this ‘spike’ in young adults to raise their levels of economic development. Other countries, such as those in the Middle East and sub-Saharan Africa, have yet to do so. Garrett Nagle explains the concept and analyses the impact it has had, and can have, on countries such as South Korea and Ethiopia.

Series contributors

David Redfern (Editor)

Paul Guinness

David Holmes

Garrett Nagle

TOPIC EYE| Licensed to: 1Population & Health 2014 |2015


‘Dengue is a mosquito-borne infection found in tropical and subtropical regions around the world. In recent years, transmission has increased predominantly in urban and semi-urban areas and has become a major international public health concern’ (World Health Organisation 2012). This is one of several infectious diseases that have increased in incidence and spread into new parts of the world in recent decades. A number of factors have contributed to the spread of these diseases including:

• increasing urban population densities;

• expanding international trade in goods;

• the continuing expansion of international travel and tourism.Dengue fever is an infectious tropical disease

caused by the dengue virus. The incidence of this disease has increased dramatically since the 1960s. According to the Natural Resources Defense Council (USA), dengue has increased 30-fold in the last 50 years. A 2012 outbreak in India affected over 30,000 people in October alone. Dengue is

transmitted by several species of mosquito within the genus Aedes. There is a simple sequence of events:

• the virus is transmitted to humans through the bites of infected female mosquitoes;

•an infected person is bitten by another mosquito which becomes infected for the first time;

• the infected mosquito then bites another person and the cycle continues.An infected mosquito can transmit the virus for

the rest of its life. Dengue can also be transmitted via infected blood products and through organ donation. Vertical transmission, from mother to child, during pregnancy or at birth, has also been recorded. Apart from mother to child, dengue fever cannot spread from person to person.

The WHO recognises four distinct but related serotypes of the virus that causes dengue fever (DEN-1, DEN-2, DEN-3 and DEN-4). A person who recovers from infection by one serotype will then be immune from further infection by that particular serotype. However, cross-immunity to the other serotypes is only partial and temporary. Later infections by other serotypes increase the risk of developing severe dengue fever.

Dengue fever is without doubt an emerging

Dengue feverThe next global threat? Paul Guinness discusses the causes of dengue fever, its growing prevalence and how this disease can be addressed.

1



disease, with cases rising dramatically in recent decades. The World Health Organisation estimates that 50–100 million infections occur each year, including 500,000 severe dengue cases and 22,000 deaths, mainly among children. In 2012 the WHO said that about half of the world’s population was now at risk.

SymptomsDengue fever causes flu-like symptoms that affect infants, young children and adults (Figure 1). It begins with a sudden high fever, with a temper-ature often over 40°C four to seven days after infection. According to the US National Library of Medicine: ‘A flat, red rash may appear over most of the body 2–5 days after the fever starts. A second rash, which looks like the measles, appears later in the disease. Infected people may have increased skin sensitivity and are very uncom-fortable’. People with dengue fever may also experience joint aches, muscle aches, headache (particularly behind the eyes), fatigue, nausea and vomiting (with blood), and swollen lymph nodes. The alternative name of ‘breakbone fever’ comes from the muscle and joint pains associated with the disease.

Figure 1 Dengue symptoms

The condition itself usually lasts a week or longer. Although uncomfortable and sometimes distressing, the disease is not usually fatal. Thus the vast majority of people should make a full recovery. Overall, only about 1% of people infected need hospitalisation. In a very low proportion of cases this disease develops into:

• life-threatening severe dengue, also known as dengue haemorrhagic fever (DHF);

•dengue shock syndrome characterised by dangerously low blood pressure.

Geographical extentDengue fever is widespread in areas with high mosquito populations where there is a combina-tion of a warm and humid climate along with high population densities and overcrowding (Figure 2).

The Aedes mosquitoes usually live between lati-tudes 35°N and 35°S, below an elevation of 1000 metres. The geographical spread of dengue fever is broadly similar to that of malaria, though the former is much more concentrated in urban and semi-urban areas. The regions affected include:

• Indonesia and northeastern Australia

•South and Central America

•Southeast Asia

• sub-Saharan Africa

•parts of the CaribbeanThe Aedes aegypti mosquito habitat is in urban

environments, breeding mostly in human-made containers. Unlike other mosquitoes, the Aedes aegypti feeds in daytime. The risk of a mosquito bite is greatest during the early morning, several hours after daybreak and in the late afternoon before sunset. However, mosquitoes may feed at any time during the day. One mosquito may bite

Dengue symptoms to watch forIf you travel to areas with dengue, symptoms to watch for include the ‘dengue triad’ of:• High fever and chills• Severe pain (headaches; eye

pain; bone, joint and muscle pain)• Rash on the arms, legs and torso, with redness

and swelling of the hands and feet

GUATEMALA

British Virgin IslandsAnguilla

Virgin IslandsSt. Kitts and Nevis

MonserratGuadeloupe

Martinique

St Vincent and the Grenadiers

Netherlands AntillesAntigua and Barbuda

Dominica

St Lucia

Barbados

Grenada

Trinidad and Tobago

MEXICO

UNITED STATES

BELIZEJAMAICA

CUBA

HONDURASNICARAGUA Aruba

HAITI

DOMINICAN REPUBIC

SURINAMEFRENCH GUIANA

The Bahamas

EL SALVADOR

COSTA RICAPANAMA

ECUADOR

COLOMBIA

PERU

CHILE

BOLIVIA

PARAGUAY

ARGENTINA

URUGUAY

VENEZUELA

BRAZIL

Galapagos Islands

(Ecuador)

PacificOcean

Atlantic Ocean

GUYANA

PacificOcean

AtlanticOcean Indian Ocean

Europe

Asia

Africa

Dengue risk areasAreas with no known dengue risk

Australia

Figure 2 The geographical extent of dengue fever



a number of people during each feeding period. Aedes albopictus, a secondary dengue vector in

Asia, has spread to Europe and North America. This has been mainly due to international trade in used tyres, bamboo products and other goods that are breeding habitats. This type of mosquito is highly adaptive and can survive in cooler temperate regions of the world. Its geographical diffusion is due to its tolerance to temperatures below freezing, hibernation and its ability to shelter in microhabitats.

Prior to the 1970s, only nine nations had reported severe epidemics of dengue fever. The disease is now endemic in more than 100 coun-tries. Sudden outbreaks of dengue fever can occur where thousands of people can become infected in a short time period. In November 2012, the European Centre for Disease Prevention and Control (ECDC) stated that Europe was experi-encing its first sustained transmission of dengue fever since the 1920s:

• In 2010, local transmission of dengue fever occurred for the first time in Croatia and France while imported cases were reported in three other European countries;

• In 2012, an outbreak of over 1800 cases on the Madeira islands (Portugal) was reported, and imported cases were detected in five other European countries apart from mainland Portugal.

Severe dengue (DHF)Severe dengue is more common in infants and young children. It results in heavy bleeding, respira-tory distress, low levels of blood platelets and blood plasma leakage. Warning signs occur three to seven days after the first symptoms along with a fall in temperature below 38°C. Such warning signs include persistent vomiting, rapid breathing and severe abdominal pain. According to the World Health Organisation (WHO), experienced medical care can substantially reduce the risk of death from severe dengue from more than 20% to less than 1%. The maintenance of body fluid volume is essential in cases of severe dengue.

The WHO has stated that ‘severe dengue (DHF) is a leading cause of serious illness and death among children in some Asian and Latin American countries’. It was first recognised in the Philippines and Thailand during dengue epidemics

in the 1950s. Now it affects most Latin American and Asian countries and has become a significant cause of death in these regions.

Diagnosis and preventionDengue fever can be diagnosed by a number of tests that include complete blood count (CBC), antibody titer for dengue virus types, and poly-merase chain reaction (PCR) for dengue virus types. The disease has no specific treatment. Typical advice is to maintain good fluid levels to avoid dehydration and to avoid taking aspirin and other non-steroidal anti-inflammatory drugs because of their anticoagulant properties.

There are various ways of reducing the risk of contracting dengue fever. For the individual, sensible measures can include wearing clothing that reduces the skin to exposure, using mosquito repellent, using netting where this is appropriate, and travelling during periods of minimal mosquito activity. On a larger scale, mosquito abatement programmes have significantly reduced the risk of infection in some areas. As the problem has increased, much more attention is being paid to vector control measures whereby relatively straight-forward methods can be used to reduce the habitat and the number of mosquitoes (Figure 4).

At present there is no vaccine avail-able to protect against dengue fever, though several possible vaccines are in various phases of trials. Pharmaceutical companies are also looking to develop medica-tion targeted directly at the virus.

The next stage?There is considerable concern about the potential spread of dengue fever in the near future. Apart from the distress to indi-viduals affected and the risk of death in severe cases, there are

significant economic and social costs involved. Climate change threatens to make the battle against dengue fever and other infectious diseases even more difficult by significantly increasing the number of people at risk. Increases in tempera-ture, rainfall and humidity create better conditions for tropical and subtropical insects to survive and multiply in locations that were previously inhos-pitable to such insects. The development of a low-cost vaccine would be a major step forward in the battle against this emerging disease. TE

Figure 3 A dengue fever information sign in a public place in Buenos Aires, Argentina, January 2013

Figure 4 Prevention and control



REVIEWKey points●● Dengue fever is an infectious tropical disease trans-mitted by mosquitoes within the genus Aedes that has increased dramatically since the 1960s.

●● It is one of several infectious diseases that have increased in incidence and spread into new parts of the world in recent decades due to increasing urban population densities, expanding international trade in goods, the continuing expansion of interna-tional travel and tourism, and climate change.

●● It causes flu-like symptoms that affect infants, young children and adults.

●● It is widespread in areas with high mosquito popula-tions where there is a combination of a warm and humid climate along with high population densities.

●● In a small proportion of cases it can develop into life-threatening severe dengue or dengue shock syndrome.

●● A vaccine is not available at present, but there are various ways of reducing the risk of contracting dengue fever.

Pause for thought●● Why has dengue fever become ‘a major international public health concern’, according to the World Health Organisation?

●● Describe the geographical extent of dengue fever.

●● If you were visiting a country where there was a risk of contracting dengue fever, what would you do to reduce the risk?

●● What can communities at significant risk of dengue fever do to reduce the incidence of the disease?

●● In what ways is climate change increasing the number of people at risk from dengue fever?

ContextThis is a disease that is causing increasing concern at the international level. Major questions that arise include the following:

●● Will the number of cases increase in countries where the disease is endemic?

●● Will the incidence of the disease increase in countries that have had few or no incidences to date?

●● Can vector control measures be significantly improved?

●● To what extent will climate change exacerbate this problem?

●● Can a vaccine and improved medication be developed in the near future?

RESPONSEAssimilation

1 What have been the main reasons for the spread of dengue fever and other infectious diseases in recent decades?

2 Describe the way in which dengue fever spreads between mosquitoes and humans.

3 Outline the symptoms of dengue fever. How do the symptoms change when dengue fever progresses to severe dengue?

4 Describe the geographical extent of the disease, referring to where it occurs in each continent.

5 How can individuals and the communities in which they live reduce the risk of contracting dengue fever?

6 What major breakthrough could impact very significantly indeed on the occurrence of dengue fever?

Evaluation

1 Describe and explain the characteristics of dengue fever and its geographical distribution.

ANSWER PLAN

●● Brief description of the way in which dengue fever is trans-mitted between infected female mosquitoes and humans.

●● An outline of the symptoms of dengue fever and severe dengue.

●● The climatic and human conditions under which the Aedes aegypti mosquitoes thrive.

●● The general latitudinal and altitudinal extent of the Aedes mosquitoes.

●● A description of the world regions affected.

●● Reference to the Aedes albopictus, a secondary dengue vector in Asia that has spread to Europe and North America.

●● Discuss the reasons why the incidence and geographical extent of dengue fever have increased so rapidly and why they are likely to increase further in the future.

●● Examine the measures that can be taken to reduce the risk of contracting dengue fever.

2 Discuss the reasons why the incidence and geographical extent of dengue fever have increased so rapidly and why they are likely to increase further in the future.

3 Examine the measures that can be taken to reduce the risk of contracting dengue fever.

Extension

1 Research the Internet to find data showing the increasing incidence of dengue fever. Draw a graph from the data using an appropriate graphical technique.

2 Visit the WHO website (www.who.int/topics/dengue/en/) to find out the status of dengue vaccine development.



O f the 57 million global deaths in 2008, 36 million (or 63%) were due to NCDs, principally cardiovascular diseases (CVD), cancers, chronic respiratory diseases, digestive diseases and diabetes (Figure 1). NCDs are the most frequent causes of death in most countries, except in Africa. As populations age, annual NCD deaths are projected to continue to rise worldwide, and the greatest increase is likely in the developing world. Even in African nations, NCDs are rising rapidly and are projected to exceed commu-nicable, maternal, perinatal and nutritional diseases as the most common causes of death by 2030.

Mortality and morbidity data reveal the growing and disproportionate impact of the NCD epidemic on developing nations (Figure 2). According to the World Health Organisation (WHO), over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from chronic obstructive pulmonary disease, occur in low-income and middle-income countries. More than two-thirds of all cancer deaths occur in these countries. NCDs also kill at a younger age in developing countries, where 48% of NCD deaths occur among people under the age of 70, compared with 26% in

high-income countries. The estimated percentage increase in cancer incidence by 2030, compared with 2008, will be greater in low-income (82%) and lower-middle-income countries (70%) than in the upper-middle-income (58%) and high-income countries (40%).

Factors affecting these trendsThere are various indicators of NCDs, as shown in Table 1 for selected countries.

Tobacco use: Almost 6 million people die from tobacco use each year (10% of all deaths), both from direct tobacco use and second-hand smoke. The highest incidence of smoking among men is in lower-income and middle-income countries. Manufactured cigarettes represent the major form of smoked tobacco – current smokers are estimated to consume about 6 trillion cigarettes annually. Other forms of tobacco are also consumed, particularly in Asia, Africa and the Middle East. Data on these additional forms of smoked tobacco are not readily available, but their use is nonethe-less substantial. In India alone, about 700 billion ‘bidis’ (a type of filterless hand-rolled cigarette) are consumed annually.

NCDs in the developing world

Source: World Health statistics 2012 (WHO)

Figure 1 Proportion of global NCD deaths under the age of 70, by cause of death, 2008

CancersCardiovascular diseases

Chronic respiratorydiseasesDiabetesDigestive diseasesOther non-communicable diseases

David Redfern looks at the growing threat posed by non-communicable diseases (NCDs) throughout the world and, in particular, in developing countries.

2



Insufficient physical activity: This is a factor more relevant to the developed world. The Americas have the highest rates of inactivity and Southeast Asia has the lowest.

Harmful use of alcohol: Approximately 2.3 million people die each year from the harmful use of alcohol (3.8% of all deaths). While adult per capita consumption is highest in high-income countries, it is nearly as high in the populous upper-middle-income countries. It is lowest in low-income countries.

Unhealthy diet: 1.7 million (2.8%) of deaths worldwide are attributable to low fruit and vegetable consumption. Most populations also consume much higher levels of salt and saturated fats than recommended by the WHO. Unhealthy diet as a factor is rising quickly in developing

nations. In relation to cancer, dietary contami-nants are a significant problem in some regions. One example is widespread – naturally occurring aflatoxins, which contaminate cereals and nuts and cause liver cancer when eaten. The association of nasopharyngeal cancer with the consumption of Chinese-style salted fish is an example.

At least 2.8 million people die each year as a result of being overweight or obese. The preva-lence of overweight is highest in upper-middle-income countries, but very high levels are also reported in some lower-middle-income countries. Raised blood pressure is estimated to cause 7.5 million deaths (12.8% of the total). Interest-ingly, the prevalence of raised blood pressure is highest in Africa, where it is 46% for both sexes combined, and lowest in the Americas, with 35% for both sexes. Raised cholesterol is estimated to

Probability of death from NCDs (%)< 20 25–29 ≥ 3520–24 30–34 Not applicable

Source: World Health Statistics 2012 (WHO)

Figure 2 Probability of death from an NCD between the ages of 30 and 70, 2008 (%)

Table 1 Indicators of non-communicable diseases: selected countries by WHO income category, 2008

Country/indicator

IndiaLower-middle- income group

Malawi

Low-income group

NigeriaLower-middle- income group

UK

High-income group

Male Female Male Female Male Female Male Female

NCD deaths under the age of 60 (% of all NCD deaths) 38 32 56 41 42 42 13 8

Death rate from all NCDs (per 100,000 people) 782 571 1208 812 818 793 441 309

Death rate from all cancers (per 100,000 people) 79 72 84 107 89 99 155 115

Death rate from CVD and diabetes (per 100,000 people) 386 283 674 500 436 476 166 102

% tobacco smoking daily 25 2 20 2 7 2 19 16

% physical inactivity 11 17 7 13 N/A N/A 61 72

% raised blood pressure 33 32 46 41 42 44 46 41

% obese 1.3 2.4 2.6 6.0 4.6 8.4 26.0 27.7% raised cholesterol 26 28 23 24 14 19 66 66

Source: WHO 2010



cause 2.6 million deaths (4.5% of the total). It is a major cause of heart disease and stroke in both the developed and developing world, though highest in high-income countries.

Impact on developmentIn 2010, the World Economic Forum (WEF) placed NCDs among the most important and severe threats to economic development, alongside the financial crisis, natural disasters and pandemic influenza. At the national level, threats and impacts of NCDs also include large-scale loss of produc-tivity as a result of absenteeism and inability to work, and ultimately a decrease in national income. The WEF estimated that countries such as Brazil, Russia, India and China (the BRIC countries) currently lose more than 20 million productive life years annually to NCDs. From 2005 to 2015, China and India are projected to lose $12,558 billion (0.93% of GDP) and $237 billion (1.5% of GDP) respectively as a result of heart disease, stroke and diabetes. By 2025, the total costs from overweight and obesity alone among Chinese adults are projected to exceed 9% of China’s GNP. According to this estimate, the expected 50% rise in NCDs predicted in Latin America by 2030 would correspond to about a 2.5% loss in economic growth rates. An Institute of Medicine study in the United States in 2010 found that NCDs cost developing countries between 0.02% and 6.77% of GDP.

The NCD epidemic strikes disproportionately the people of lower social positions within the developing countries. People here are increasingly eating foods with higher levels of total energy and are being targeted by marketing for tobacco, alcohol and junk food, while availability of these products increases. Overwhelmed by the speed of growth, many governments are not keeping pace with ever-expanding needs for policy, legislation and healthcare services that could help protect their citizens from NCDs.

Since most patients in poorer countries are burdened by out-of-pocket healthcare costs, treatment for NCDs creates significant strain on household budgets, particularly for lower-income families. Treatment for diabetes, cancer, cardio-vascular diseases and chronic respiratory diseases can be protracted and therefore extremely expen-sive for individuals and their families. Such costs can force families into very high spending and impoverishment. The cost of dealing with NCDs and the behavioural risk factors that cause them

translates into less money not only for necessities such as food and shelter but also for the basic requirement for escaping poverty – education.

Specific issuesThe World Health Organisation (WHO) has produced a report that has raised a number of issues associated with NCDs. Some examples are listed below.

Alcohol: Romanians spend an average of 11% of family income on alcohol, and Zimbabwean households average 7%. However, national averages conceal the impact on families of drinkers – families with frequent-drinking husbands in New Delhi spent 24% of family income on alcohol, compared to 2% in other families. Surveys among the urban poor in Sri Lanka found that 30% of families consumed alcohol and spent more than 30% of their income on it.

Tobacco: Data from Nepal indicate that the poor spend 10% of their income on cigarettes. In India, the risk of the selling of valuable assets was notably higher for hospitalised patients who are smokers. Studies in China showed that tobacco use increased the odds of sick leave by between 32% and 56%.

The costs of NCD treatment: One month of treatment for coronary heart disease costs 18.4 days’ wages in Malawi, 6.1 days’ wages in Nepal and 5.4 days’ wages in Pakistan. The cost of one month of treatment for asthma ranges from 1.3 days’ wages in Bangladesh to 9.2 days’ wages in Malawi. In India, paying for diabetes care can cost poor households about one-third of their incomes. In Tanzania, household costs for diabetes treat-ment were found to be 25% of the minimum wage. National healthcare budgets are also being increasingly allocated to the treatment of NCDs. Costs for treating diabetes range from 1.8% of GDP in Venezuela to 5.9% in Barbados. For the Latin America region, diabetes healthcare costs were estimated at around $65 billion annually, or between 2% and 4% of GDP (8–15% of national healthcare budgets).

ConclusionThe NCD epidemic is exacting a massive socio-economic toll throughout the world and this is rising rapidly in developing countries. It is thwarting efforts to reduce poverty and robbing societies of funds that could otherwise be devoted to social and economic development. TE



REVIEWKey points●● Most global deaths are the outcome of non-communicable diseases such as heart disease, diabetes and cancer.

●● These NCDs are as common in most developing countries as they are in the developed world.

●● The risk factors are similar to those in the devel-oped world – tobacco use, physical inactivity, overuse of alcohol and poor diet.

●● NCDs are having a significant impact on economic and social development in the developing world.

●● This impact greatly affects a developing country at a national scale, and also the individual people and their families involved.

●● Costs on budgets, national and household, are substantial and disproportionate.

Pause for thought●● Bearing in mind that the developed world has ‘suffered’ from NCDs for several decades, to what extent should expertise be shared with the devel-oping world? Does the latter have the capacity to cope?

●● Is this a new market area for developed world TNCs, or are they largely to blame?

●● What has been the role of globalisation in the spread of NCDs? Is it a case of the poorer world emulating the lifestyle of the richer world?

●● Should supranational bodies, such as the WHO, take responsibility for the monitoring and surveil-lance of the rise of NCDs, or is it more the role of national bodies?

●● As the incidence of many NCDs is linked to human behaviour and personal choices of lifestyle, to what extent should governments influence these aspects of living?

ContextThe study of health issues is a popular topic at A-level and, in particular, the examination of the nature, causes and impacts of a range of diseases. In many cases attention is drawn to infectious disease, such as dengue fever (see previous article, pp. 2–5). However, the main causes of death across the world, except in Africa, are due to NCDs. The impact of these diseases on both individual households and national governments is significant, with implications for economic development not only in terms of loss of productivity but also in terms of healthcare budgets.


1 Outline why NCDs are having a ‘growing and disproportionate impact’ on developing nations.

2 Why is the use of tobacco a key factor in NCDs in the developing world?

3 Why are unhealthy diets becoming an increasingly important causal factor in the developing world?

4 Explain why the World Economic Forum states that NCDs are a severe threat to the economic development of many developing countries.

5 Describe why NCDs cause so many difficulties to the families of the individuals affected.

Evaluation

1 Discuss the impacts of one non-communicable disease.

ANSWER PLAN

●● Clear and precise description of the impacts of one NCD.

●● Some analysis of the impacts – possibly by categorising them into social and economic.

●● Explicit discussion of the impacts – for example, how they may affect different members of a society, or may have different outcomes depending on the availability of treatment in some areas.

●● A clear sense of debate should be given towards the end of the answer.

●● Include detailed use of case study material that is appropriate for the task.

2 Study Figure 2. Describe the pattern of percentage probability of death from an NCD between the ages of 30 and 70 in 2008.

3 Study Table 1, which shows various indicators of NCDs in selected countries according to WHO income categories. Describe and comment on the information shown.

4 Suggest strategies that could be put forward by a national government to try and reduce the scale of early deaths caused by NCDs.

5 ‘Non-communicable diseases are largely preventable. They can be treated and controlled.’ To what extent do you agree with this view?

Extension

1 The World Health Organisation publishes a great deal of information on the growth and impact of NCDs. Go to its website at http://www.who.int/en/ and investigate either of the Health topics or Data and statistics tabs for further research on any NCD of your choice.

2 ‘Childhood obesity in India is becoming a major problem.’ Investigate this issue. The following provide interesting starting points: http://www.cseindia.org/userfiles/presentation_cse.pdf and http://obesityfoundationindia.com/.



http://www.who.int/en/

http://www.cseindia.org/userfiles/presentation_cse.pdf

http://obesityfoundationindia.com/

T he census is the only survey that provides a detailed picture of the entire population. It is unique in that it covers everyone at the same time and asks the same questions everywhere, making it easy to compare different areas at a range of scales (Figure 1). The census not only collects data on households but also includes those living under one roof in establishments such as care homes and boarding schools.

It even includes British citizens who are abroad, e.g. the armed forces, and people who are homeless.

The census is vital because it allows local and central government, health authorities and other organisations to target their resources in terms of housing, education, health and transport services. However, the 2011 Census was controversial. At a staggering cost of an estimated £450 million, there is a creditable argument that much of the data can be gathered from elsewhere (computer records etc). Another failing of the census is that the data are almost ‘out of date before it is done’ (Francis Maude, Cabinet Office Minister, 2010). And there is, of course, the question of reliability. It was reported that 390,000 people described their religion as ‘Jedi Knight’ in the 2001 Census!

Nevertheless, the census provides geographers with an incredibly rich seam of geographical data to explore. Local census data (geodemographic information) provide key research information that may be used to support and challenge primary fieldwork data.

Exploring the2011 Census

The census is a giant snapshot of the whole nation taken every 10 years. David Holmes examines the ideas behind the 2011 Census for England and Wales and describes the key outcomes in the context of the 2001 Census.

Figure 1 The 2011 Census form

3



Understanding UK census geographyUK census geography comprises a number of geographical ‘building blocks’. The base units are Output Areas (OAs). All other areas – Super Output Areas (SOA layers) – are just aggregations of these areas (Figure 2).

Each geographic area of the census is given a unique numerical code. In an example from North Norfolk, the first number quoted repre-sents the Local Authority Code, i.e. ‘33UF’. The next series of digits, ‘GT0004’, is a coding for the highest resolution of census data available, i.e. for a specific Output Area.

Key changes in the UK census geography, 2001–11 Releases of data from the 2011 Census is an ongoing process, but one of the first main releases was in late 2012 and this document highlighted a number of features (Table 1).

GOR – Government Of�ce Region. There are 9 of these in England Counties/Local Authority Districts/Unitary Authorities/London Boroughs

Middle layer SOAs: 6870 units; minimum 5000 people; average 7200 people

Lower layer SOAs: 32,482 units; minimum of 1000 people; average of 1500 people

Output Areas: 165,665 units; minimum of 100 people; average of 300 people

Increasingly sm

aller area and hig

her reso

lution o

f data o

utput/d

etail

Figure 2 A simplified census hierarchy for England

Changes in health and caring

●● 10% (5.8 million) of residents of England and Wales in 2011 provided unpaid care for someone with an illness or disability. This was the same percentage as in 2001. Over a third (37%, 2.1 million) of these people were giving 20 or more hours care a week – an increase of 5% (473,000) on 2001 (32%, 1.7 million).

●● In 2011, 81% (45.5 million) of residents of England and Wales described themselves as being in good or very good health. This cannot be directly compared with 2001 as a different question was asked in the previous census.

Changes in housing and tenure

●● The number of people privately renting homes increased significantly from 2001 to 2010. There were 3.6 million homes rented from a private landlord or letting agency in 2011 (15% of households), whereas there were 1.9 million rented homes (9%) in 2001. There was a decline in homes owned with a mortgage, from 8.4 million (39% of households) in 2001 to 7.6 million (33%) in 2011.

Changes in education

●● In 2011 there were 27% (12.4 million) of residents aged 16 and over with Level 4 or above qualifica-tions, e.g. degree level. (Although not a new question in 2011, some of the qualification estimates are not directly comparable with 2001.) For the first time, this was more than those with no qualifications – 23% (10.3 million) in 2011.

Changes in car ownership

●● The number of cars and vans available for use by households in England and Wales increased from 23.9 million to 27.8 million between 2001 and 2011. In 2001 there were on average 11 cars per 10 households, whereas in 2011 there were 12 cars per 10 households. The proportion of households with access to no cars or one car declined over the decade, whereas the proportion with two or more cars rose.

Notes: The smallest of these units (the lowest layer in the hierarchy) are the Output Areas (OAs). These are geographic areas based on small groups of postcodes (typically two or three). The next two layers up the hierarchy are termed ‘Super Output Areas’. It is these layers in the census geography that are most widely used by decision makers to plan for new infrastructure. The top of the hierarchy is made up of regions and counties that are then subdivided into Local Authority Districts (LAD) or Unitary Authorities (UA).

Table 1 2011 Census: key statistics for England and Wales, March 2011

Changes in population

●● The resident population of England and Wales on 27 March 2011 was 56.1 million, a 3.7 million increase since 2001 with 55% (2.1 million) of this increase being due to migration. The greatest percentage increase was in London (Figure 3).

●● The population aged over 90 rose from 0.7% (336,000) in 2001 to 0.8% (429,000).

Changes in religion

●● There was a decrease from 37.2 million (72% of residents) to 33.2 million (59% of residents) between 2001 and 2011 in the number of people who stated that they were Christian (Figure 4). The size of the group that declared no religious affiliation increased considerably, from 7.7 million in 2001 to 14.1 million in 2011 (15% to 25%).

●● The third most popular category was Muslim, with numbers rising from 1.5 million (3%) to 2.7 million (5%) over the 10 years.

Changes in ethnicity

●● Most residents of England and Wales belonged to the white ethnic group (86%, 48.2 million) in 2011, and the majority of these belonged to the white British group (45.1 million).

●● In 2011, 12% (2.0 million) of households with at least two people had partners or household members of different ethnic groups, a 3% increase on 2001 (9%, 1.4 million).

Migration changes

●● More than half of the 7.5 million foreign-born residents living in England and Wales in 2011 had arrived in the last 10 years. Foreign-born residents made up 13% of the population in 2011 – up from 9% in 2001, when there were 4.6 million residents born outside the UK.



Some interesting place geography of the 2011 censusThe census reveals not only changes at a national level, but also some surprising geographies at local or regional levels. Below are four snippets of census data that make certain places stand out (for both ‘good’ and ‘not so good’ reasons).

(1) Blackpool – divorce capital

The Lancashire seaside resort had the highest percentage of people who are divorced: 13.1% compared with the average for England and Wales of only 9%. Seaside resorts are often near the top of the divorce league, though no-one is really sure why.

(2) Not much central heating in the Scilly Isles

In 2011 26.3% of the population of the Scillies stated that they did not have central heating while the England and Wales average was 2.7%. The Isles of Scilly are warmed by the Gulf Stream and

have a climate similar to the Channel Islands. Typically the islands do not have harsh winters, and transporting heating oil from the mainland is expensive.

(3) Health inequalities

Regionally London had the highest percentage of residents describing their health as very good (50%), whereas the Northeast of England had the lowest figure (44%). Wales and the Northeast of England had the highest percentages of usual resi-dents reporting bad or very bad health: 8% and 7% respectively. The Southeast had the smallest percentage of residents reporting to be in either bad or very bad health, at only 4%. Differences in health can be complex to explain, but they are often to do with family history and cultural factors linked to diet and lifestyle.

(4) Lots of single people in Islington, London

Islington has the highest number of single resi-dents. Nearly 60% of people aged over 16 are not in a relationship. That is the highest percentage of singletons (people who have never married or registered a same-sex civil partnership) in England and Wales. The pattern is repeated across other London boroughs, e.g. Lambeth (58.4%) and Hackney (57.5%), with the average for England and Wales standing at 34.6%. Researchers suggest that single status is part of a wider pattern of people living alone in city centres. Cities also tend to have certain ‘hotspot areas’ where singletons congregate.

ConclusionsThe census has always been an important, yet controversial, piece of geographical research. As more data are revealed, analysts can begin to unpack the complex spatial patterns of popula-tion and then ask further geographical ques-tions. A knowledge and understanding of the significance of the census is clearly important for a range of stakeholders with different needs and backgrounds. Indeed, high resolution and localised census data are likely to become more com mercially important in the future as a greater number of connections are made between a range of geo-demographic data sets that describe the characteristics of households and places. While it is therefore likely that some sort of popula-tion census will always be necessary, the paper- based 2011 Census may very well be the last of its kind. TE

London

East of England

East Midlands

Southeast

England

Southwest

Yorkshire andthe Humber

West Midland

Wales

Northwest

Northeast Source: 2011 Census

0 5 10 15(%)

Christian0

20

40

60

80

Noreligion

Muslim Hindu Sikh Jewish Otherreligion

71.7

59.3

25.1

14.8

3 4.81.1 1.5 0.6 0.50.50.8 0.6 0.8

Note: Remainder did not state religion.

Source: ONS

2001 2011 (%)

Figure 3 Population increases by region, 2001–11(%)

Figure 4 Changes in religion, 2001–11 (%)



REVIEW Key points●● The census is important in terms of resource allo-cation and planning of infrastructure, especially roads, housing, schools, etc. It is also important for justifying big capital projects, e.g. HS2.

●● A government agency – the ONS (Office for National Statistics) – is responsible for the delivery and processing of all the census data.

●● There have been significant changes in much of the geography of England and Wales between 2001 and 2011, including big changes in ethnicity, migration and religion; overall population (England and Wales) was up by 7%.

●● There were changes to the 2011 Census, e.g. questions relevant to civil partnerships and asking migrants their date of arrival and how long they intend to stay in the UK.

Pause for thought●● What will become of the census in 2021? How might it be organised and how will data be collected? What role might technology play?

●● To what extent do all places share similar population characteristics? What factors may be responsible for causing regional variations in demographics?

●● How comparable is the census from one decade to the next?

●● What happens if there is significant change in the population of an area which is not picked up because the census is only every 10 years?

ContextThis article examines a range of ideas relating to changes between the 2001 and 2011 censuses for England and Wales:

●● economic development of local areas and regions will depend on the census outcomes and subsequent resource allocation;

●● the 2011 Census reveals patterns of an increas-ingly globalised society in England and Wales through patterns of migration;

●● with increasingly limited resources, decision makers and governments face tough decisions in terms of the best resource allocation for groups and communities;

●● with populations becoming more mobile, the census reveals the processes of population movement.

RESPONSEAssimilation1 Describe the geographical hierarchy and spatial geography of how the

census is organised.

2 Give the key reasons why a census is taken every 10 years.

3 What possible impacts result from the significant changes in car and van ownership from 2001 to 2011?

4 Comment on the changes that have occurred in housing tenure over the last 10 years.

5 Outline some of the complex and sensitive issues surrounding the changes in the overall population of England and Wales.

6 Which places are health inequality hotspots? Comment on the reasons for the spatial differences, including ideas around culture and background.

Evaluation1 Using your own knowledge and research, comment on the changes in

the degree of migration revealed by the latest census.

ANSWER PLAN

There are a number of key patterns and possible reasons:●● Increases in the number of migrants due to EU border control changes.●● More flexible workforce, with employees bringing their families from

overseas. This is especially true for larger companies that have offices in various cities.

●● Personal choice and quality of life may bring people to England and Wales.

●● Increases in foreign-born residents are an increasingly global pattern, which does not just affect England and Wales.

●● There are spatial differences, with migrant hotspot areas being revealed. In Boston, Lincolnshire, the number of immigrants in recent years has trebled to 7500.

2 Why might the census generate data that are unreliable or cannot be wholly trusted?

3 ‘The 2011 Census has revealed substantial changes in the demography of England and Wales.’ Discuss.

4 With reference to located examples, explain the ways in which cities provide a particular focus for singletons.

Extension1 Has the population change in England and Wales in the last 10 years

been strongly influenced by migration?

2 Visit the ONS website via this link: http://www.neighbourhood.statistics.gov.uk/dissemination/. Explore the local statistics and find out about your local neighbourhood (summary report). Compare differences and make suggestions about the particular geographies revealed.

3 Visit http://www.youtube.com/watch?v=yFhfw-NuUHo and describe the key ideas from The Guardian report.

4 Research how the rich geodemographic data are enormously valuable to a range of stakeholders in the twenty-first century.



http://www.neighbourhood.statistics.gov.uk/dissemination/

http://www.neighbourhood.statistics.gov.uk/dissemination/

http://www.youtube.com/watch?v=yFhfw-NuUHo

http://www.youtube.com/watch?v=yFhfw-NuUHo

On 27 July 2012, during the opening ceremony of the London Olympic Games, the artistic director Danny Boyle produced a display that celebrated to the world the National Health Service (NHS) of the UK (Figure 1). Yet despite its world renown, this cherished institution is about to undergo massive reorganisation.

Meanwhile, in the United States of America, President Barack Obama, a Democrat, has over-

seen substantial changes in healthcare in that country. However, these changes have a long way to go and it is clear that one half of the political divide there, the Republican Party, is determined to undermine or even repeal them. What is the nature of these two sets of changes and why have they created so much debate?

Changes to the NHSThe NHS is a very large and complex organisa-tion. In 2010 it was the seventh largest single employer in the world, with 1.4 million employees. The changes are about who makes decisions and who spends the money. Previously, 152 bodies called Primary Care Trusts (PCTs) controlled local spending on dentists, hospital operations and tests, and medicines, all of which accounted for 80% of NHS spending. They were mostly made up of health managers. Private health companies or charities provided some care as well. There was also NHS spending, controlled nationally, on things like specialist care.

From April 2013 PCTs in England were replaced by more than 200 GP-led organisations called Clinical Commissioning Groups (CCGs). They are responsible for close to 60% of the NHS budget. Every GP surgery has to belong to a CCG, though in reality only a small number of

Healthcare provision in the UK and USAThe provision of healthcare in the UK and USA is under-going a transformation. David Redfern considers the changes and why they have caused so much controversy.

Figure 1 The NHS takes centre stage at the opening ceremony of the London 2012 Olympics

4



GPs will take responsibility for deciding which local services to fund. Ministers believe GPs will be more responsive to the needs of patients as they have day-to-day contact with them. This, the theory goes, will make the NHS more efficient and improve the quality of care. CCGs will decide on whether or not to pay for any hospital care that a GP thinks is needed, as PCTs do now.

The government says CCGs will be better placed to decide on local priorities because more doctors and nurses will be involved. Some GPs are keen to get more involved in these decisions, but others fear factoring in costs will compromise the doctor–patient relationship.

Currently, most care is provided by NHS organ-isations. However, some routine operations are carried out by private companies but paid for by the NHS. Under the new system, a regulator called Monitor will be given the job of making sure that there are opportunities for private companies and charities to compete with NHS organisations to provide care. The government says Monitor will also have to ensure competition does not affect the service patients receive.

The Health Secretary will continue to set policies for the NHS, such as waiting times. The NHS Commissioning Board will take charge of overseeing the NHS on behalf of the Department of Health via four regional offices (Figure 2). It will control a significant part of the overall budget so that it can plan and buy specialist services, and it will also be charged with ensuring CCGs do not overspend their budgets. Local councils are to have more of a role in tackling public health problems in their area, such as obesity, and new Health and Wellbeing Boards will help link this work with that of the CCGs. A national body called Healthwatch is being set up to enable patients to have their say about the NHS.

Changes to healthcare in the USAIn the USA the healthcare system is provided by a collection of independent and private doctors, pharmacies, clinics and hospitals. The majority of people pay by means of various forms of insur-ance cover. Most of the population under 65 is insured by their employer or a family member’s employer; some buy health insurance on their own, and the remainder, just under 50 million, are uninsured. Healthcare for public sector employees is primarily paid for by the government, and there are also a number of programmes outside of the private provision:

•Medicaid – medical care for the poor;

•Medicare – medical care for the poor elderly;

•The Veterans Health Administration – medical care for former soldiers.According to the World Health Organisa-

tion (WHO), the United States spends more on healthcare per capita, and more on healthcare as a percentage of its GDP, than any other nation. It spends more than twice as much per capita as the UK (Table 1). On the other hand, the numbers and proportions of uninsured people have also increased (Figure 3).

Public Health,England Healthwatch NHS Commssioning Board

Department of Health

Secretary of State

RegionalOf�ce

Local Council

Health and Wellbeing Boards

RegionalOf�ce

RegionalOf�ce

27 Local Of�ces

212 Clinical Commissioning Groups

RegionalOf�ce

Primary Care

Monitor

New

Hospital Care

Community Care

Mental Care

Source: BBC

Figure 2 Overall structure of the new NHS in England

Indicator UK USA

Under 5 years mortality rate (per 1000 live births)

5

8

Maternal mortality rate (per 100,000 live births)

12

21

HIV prevalence (per 100,000 people)

132

391

Incidence of TB (per 100,000 people)

13

4

Life expectancy at age 60 (years)

23

23

Total health expenditure per capita ($)

3440

7960

Source: World Health Statistics (WHO) 2012

Table 1 Selected health indicators for the UK and USA



In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act. A large number of significant changes to healthcare, designed to eliminate ‘some of the worst practices of the insurance companies’, have been introduced and they will continue until 2018. They include the following:

• Insurance companies will be barred from dropping people from coverage when they get sick.

•Limits on the amount of healthcare a person can have, either over a lifetime or a year, will be eliminated and/or restricted.

• Insurers will be barred from excluding children from coverage as a result of pre-existing conditions.

•Young adults will be able to stay on their parents’ health plans until the age of 26. (Many health plans currently drop dependants from coverage when they turn 19 or finish college.)Uninsured adults with a pre-existing condition will be able to obtain health coverage through a new programme.

•Medicare will provide 10% bonus payments to primary care physicians and surgeons – previously they were paid less money than in the private sector.

•Medicare hospitals will also be given incentives both to improve and to reduce preventable readmissions.

•A new programme under the Medicaid plan began in 2012. This allows states to offer home- and community-based care for the disabled who might otherwise require institutional care.

•By 2015 most people will be required to obtain health insurance or pay a fine if they do not. Tax credits will be available to help people on low incomes.

•A web-based health insurance exchange, where consumers can compare prices and purchase plans, has been developed. Overall, the reforms preserve private insurance

and private healthcare providers while providing more subsidies to enable the poor to buy insurance.

Why have both sets of changes caused such controversy?In the UK there has been a barrage of criticism from medical trade unions and professional bodies. The British Medical Association (BMA) has argued that the reforms will fragment and disrupt patient care. Others say that the changes will lead to increased health inequalities, more bureaucracy and wasted public funds. There has also been evidence of public opposition. There have been thousands of signatures on an e-peti-tion calling for the changes to be dropped, and opinion polls have suggested widespread public opposition. The NHS is sensitive territory for any government, with one commentator describing the changes as an ‘unexploded bomb underneath the Conservative Party’.

In the USA the legislation has been challenged by some states in the federal courts. In June 2012, in a 5–4 decision, the US Supreme Court found the law to be constitutional. The Republican Party is philosophically opposed to the idea that the federal government should help working people, or non-working people, to buy health insurance if they cannot afford it themselves. Republicans favour ‘small government’, with less ‘tax and spend’ on education and welfare programmes such as Medicare and Medicaid. In their view, the health reforms bear the hallmark of a failing ‘socialist’ system such as that in the UK. Democrats disagree. They favour ‘big government’, with higher levels of taxation and higher spending on education and welfare. For them, healthcare is a right.

ConclusionTwo historically very different healthcare systems are introducing new approaches based on the benefits in the function and delivery of the other, drawing the systems closer together. Perhaps this should not surprise us, given that they both have the same goal – to provide high quality, affordable access to healthcare for their respective populations. However, the changes are controver-sial and it is clear that in both countries the debate about healthcare is set to continue for several years to come. TE

50

45

40

35

30

25

20

15

10

5

02000 2002 2004

Uninsured rate

Number uninsured

Source: US Census Bureau

2006 2008 2010

Figure 3 Healthcare in the USA: numbers uninsured and rates of uninsurance, 1999–2010 (numbers in millions; rates in %)



REVIEWKey points●● Significant changes in healthcare in both the UK and USA are being undertaken during this decade.

●● In the UK, there is greater emphasis on giving responsibility to groups of GPs to decide on the nature of healthcare in an area.

●● There will be more opportunities for private companies and charities to become involved in general healthcare.

●● In the USA, most people pay for their healthcare through insurance, but over 50 million people have no cover.

●● The changes in the USA require people to take out insurance, with support for those on low income. Some unfair practices of the current system will be eliminated.

●● Both sets of changes have resulted in great controversy in the respective countries, for varying reasons.

Pause for thought●● To what extent should access to good healthcare be free at the point of use?

●● Should there be a division in the care of diseases and conditions that have been contracted naturally and those that are the result of lifestyle?

●● What role should private organisations play in the provision of public services?

●● What is the best way to run a country – ‘big government’ or ‘little government’?

●● To what extent does either the UK or the USA provide a model of how to run a country’s health-care system for the rest of the world?

ContextThe study of health issues is a popular topic of several GCE Geography courses. While there is some emphasis on the causes, impacts and responses to both infectious and non-infectious diseases and conditions, the degree to which healthcare systems vary around the world is also an important element. The current healthcare systems of the UK and USA are characterised by their differences in ideology – the former is essentially public and the latter private. Interestingly, these two systems are seemingly moving towards each other as a result of change, and these movements are not being greeted with overwhelming support by all stakeholders.


1 Describe the current way in which the NHS is organised.

2 Summarise the main changes that have taken place in how care is decided in your area.

3 Outline the role of each of the organisations Monitor and Healthwatch in the new NHS.

4 Describe the current way in which healthcare is organised in the USA.

5 What are the changes taking place to the Medicare programme?

6 Why do many people in the USA object to the changes that are taking place?

Evaluation

1 Comment on the contrasting healthcare approaches in countries at different stage of development.

ANSWER PLAN

●● Description of the healthcare approaches in two countries that are at different stages of development.

●● (Note: The UK and USA would be viewed as being at the same stage of development.) Clear contrasts should be drawn out.

●● Explicit comment on those contrasts, such as reasons for them or their outcomes.

●● Demonstrate some understanding of political differences that may exist.

●● Detailed use of case study material that is appropriate for the task.

2 Study Table 1. To what extent do these statistics demonstrate different outcomes from healthcare in the UK and USA?

3 ‘The United States is among the few industrialised nations in the world that does not guarantee effective access to healthcare for its population.’ To what extent is this true?

4 Discuss the varying attitudes to healthcare issues in both the UK and USA.

5 To what extent can it be argued that some human rights are the preserve of individual nations, whereas other human rights are the remit of supra-national bodies?

Extension

1 In 2008, a survey in the USA found that less than half of the population of the country thought that they had the best healthcare system in the world. Visit http://people.howstuffworks.com/10-health-care-systems.htm#page=0 which provides one American’s opinion of 10 other health-care systems in the world. Devise a table of strengths and weaknesses of the systems described.

2 Table 1 provides some comparative statistics for the UK and USA from the World Health Statistics Report in 2012. Visit http://www.who.int/gho/publications/world_health_statistics/en/index.html and keep up to date with these and other health indicators.



http://people.howstuffworks.com/10-health-care-systems.htm#page=0

http://people.howstuffworks.com/10-health-care-systems.htm#page=0

http://www.who.int/gho/publications/world_health_statistics/en/index.html

http://www.who.int/gho/publications/world_health_statistics/en/index.html

T he demographic dividend refers to the economic gains that can be derived from an increase in the working population. It occurs when fertility rates decline, allowing faster economic growth. The decline in fertility often follows a decline in infant and child mortality rates, as well as increased life expectancy. As families recognise that fewer children will die during infancy or childhood, they begin to have fewer children. However, this drop in fertility rates is not immediate. The lag between falling death rates and falling fertility produces a bulge in the population that surges through age groups (cohorts). For a period of time this ‘bulge’ increases the dependency ratio. Eventually this cohort begins to enter the workforce. As fertility rates continue to fall and the elderly population still has relatively short life expectan-cies, the dependency ratio drops dramatically. With fewer younger dependants and fewer older dependants, the largest segment of the population is people of productive working age, leading to the demographic dividend.

Mechanisms for growth in the demographic dividendThe demographic dividend can deliver a number of benefits. The first is the increased labour supply. However, this depends on the ability of the economy to absorb and productively employ the extra workers. The second is the increase in savings. As the number of dependants decreases, individuals can save more. Thirdly, decreases in fertility rates result in healthier women and fewer social and economic pressures at home. This also allows parents to invest more resources per child, leading to better health and educational outcomes. Finally, the increasing domestic demand brought about by the increasing GDP per capita and the decreasing dependency ratio leads to economic growth.

The challenge of attaining the demographic dividendMany countries in Asia and Latin America have experienced impressive economic growth over the last two decades. These gains are due, in

The demographic dividend A window of opportunity?

Garrett Nagle explains the

concept of the demographic dividend and assesses the prospects for sub-Saharan

Africa.

5



part, to the ‘demographic dividend’. However, the least developed countries will be challenged to achieve the economic benefit without substan-tially lowering birth and child death rates, i.e. the ‘demographic transition’. While child survival has greatly improved in developing countries, birth rates remain high in many of them, especially in parts of sub-Saharan Africa.

In the world’s least developed countries, more than 40% of the population is under age 15 and depends on financial support from working-age adults aged 15 to 64. Another 90 million people between aged 15 and 19 are on their way to becoming financially independent as they enter adulthood.

In order to achieve a demographic transition, countries must focus on providing women with voluntary family planning information and services. One in four women in developing countries wants either to avoid becoming pregnant or to delay or space births but is not using a modern family planning method.

The demographic dividend and family planningWhile fertility has declined in most countries in sub-Saharan Africa, women in the region today still have on average 5.1 children. However, norms related to family size are changing and parents are choosing to have smaller families.

Investment in voluntary family planning helped Thailand, for example, to accelerate economic growth and this provides a model for sub-Saharan African countries. Thailand’s contraceptive use increased from 15% in 1970 to 80% by 2012, and fertility levels declined from 5.5 children per woman in 1970 to 1.6 by 1990.

Rwanda is one of several countries in eastern and southern Africa where investments in volun-tary family planning and child survival have led to significantly lower fertility. Child mortality has been cut in half in just a decade, modern contra-ceptive use has increased more than fourfold, and Rwandan women are having on average 4.6 chil-dren. If this progress continues, by 2030 Rwanda will have achieved the demographic conditions necessary for accelerated economic growth.

Improved health, education and gender equality While family planning is necessary for establishing the conditions for a demographic dividend, invest-ments in child health, education (Figure 1) and

gender equality are critical additional steps that contribute to family planning use and economic growth.

The promotion of healthy timing and spacing of pregnancies can improve child health. Children conceived less than two years after the previous birth have a substantially higher risk of dying (1.5–3 times higher) than those children conceived three or more years after the previous birth.

Girls’ education, especially at the secondary level, helps delay marriage and first pregnancy. Women who are educated are also more likely to work outside the home, increasing the size of the labour force and the potential for economic development.

Recommended actions The demographic dividend in many developing countries remains a possibility. However, for the process to begin, countries must give high priority to substantially lowering fertility and child mortality by taking the following actions:

• investing in child survival and health programmes;

• committing to voluntary family planning to achieve the demographic transition;

• investing in the reproductive health needs of both married and unmarried youth;

•prioritising education, especially secondary education for girls.

Ethiopia and the demographic dividendSince 2000, Ethiopia has made very good progress in improving the health and development of its people. Infant and maternal mortality are on the decline, under-5 mortality has been cut in half and literacy has nearly doubled. In addition, women’s reproductive health has increased greatly: among married women, use of modern contraceptive methods has grown from 6% in 2000 to 27% of married women in 2012; women are now having on average 4.8 children compared with 6.5 a decade ago; and in Addis Ababa, the capital, women on average have just over two children.

However, Ethiopia will have to increase its investments in meeting family planning needs substantially in order to create the age structure needed for a demographic dividend. More than 40% of the population is under age 15, and the population pyramid in 2010, despite the declines in mortality and fertility, is still dominated by a large base of young people (Figure 2).

Figure 1 Improvements in education can help deliver the demographic dividend to sub-Saharan Africa



By 2030 Ethiopia will just approach the age structure conditions that can facilitate accelerated economic growth.

South Korea’s demographic dividendThe ‘Asian Tigers’ are good examples of the advantages to be gained when changes in fertility

can be a springboard for economic growth. South Korea made a rapid transition from high to low fertility between 1960 and 1990. Its success was the result of addressing population issues while also investing in reproductive health programmes, education and economic policies to create infra-structure and manufacturing.

A rapid fertility transition

Between 1950 and 1975, fertility dropped from 5.4 children per woman to 2.9. However, by 2005, fertility had dropped to 1.2 children per woman, reducing the base of young people dramatically (Figure 3).

South Korea followed an aggressive population policy. The government invested in health centres to provide a range of services including family planning. Field workers visited homes and provided family planning information and methods. People saw that having fewer children improved family life.

Shifting the education strategy

The government also focused on education. Between the 1950s and 1960s, South Korea’s education strategy shifted from one of compulsory primary education, which served only about 54% of school-age children, to a ‘production-oriented’ education that would provide people with the knowledge and skills they needed to achieve economic development.

Comprehensive economic plans

At the same time, South Korea’s economic plans were comprehensive. In the 1950s its economy was weak, based largely on farming and fishing. Improved relations with Japan led to investment capital that strengthened agricultural, fishing and manufacturing industries, including shipping. The South Korean government also addressed unemployment through a rural construction programme that provided minimum wages for workers involved in the construction of infra-structure, including dams and roads. This effort contributed to economic growth.

After the demographic dividendThe demographic dividend offers a ‘window’ of opportunity. The dependency ratio begins to increase again as the population cohort that created it grows old and retires. With a disproportionate number of old people relying upon a smaller gener-ation following behind them, the dividend becomes a liability. TE

10 10

10 10

10 10

468 2 0 0 2 4 6 8

Age80+

75–7970–7465–6960–6455–5950–5445–4940–4435–3930–3425–2920–2415–1910–14

5–90–4

Male Female

Percentage of population

South Korea 1950

South Korea 1975

South Korea 2005

468 2 00 2 4 6 8

Age80+

75–7970–7465–6960–6455–5950–5445–4940–4435–3930–3425–2920–2415–1910–14

5–90–4

Male Female


468 2 00 2 4 6 8

Age80+

75–7970–7465–6960–6455–5950–5445–4940–4435–3930–3425–2920–2415–1910–14

5–90–4

Male Female


45 3 678 2 1 0 1 2 3 4 5 6 7 8 45 3 678 2 1 0 1 2 3 4 5 6 7 8

Age95-9990–9485–8980–8475–7970–7465–6960–6455–5950–5445–4940–4435–3930–3425–2920–2415–1910–14

5–90–4

Male Female


Male Female


Ethiopia 2030Ethiopia 2010

Figure 2 Ethiopia’s age and sex structure, 2010 and 2030

Figure 3 South Korea’s age and sex structure, 1950, 1975 and 2005



REVIEWKey points●● The demographic dividend refers to the bulge in the young adult population.

●● It is caused by a fall in fertility rates and a small elderly population.

●● It can bring many benefits, such as reduced spending (on children) and increased savings.

●● Benefits occur at a household level and at a national level.

●● South Korea is a good illustration of the impact of a demographic dividend.

●● Many African countries, including Ethiopia, will not experience a demographic dividend for about 20 years.

●● The demographic dividend offers a ‘window’ of opportunity.

Pause for thought●● With fewer births each year, a country’s young dependent population grows smaller in relation to the working-age population. With fewer people to support, this gives a country an opportunity for rapid economic growth if the right social and economic policies are developed and investments are made.

●● The demographic dividend only occurs if there are enough jobs for all the adults. If there are not enough jobs, it could lead to increased unemployment and poverty.

●● Countries that experience a demographic dividend will experience an increase in their elderly population some 40 years later.

ContextThe demographic dividend can be seen as part of the demographic transition. Typically it occurs as a result of falling fertility combined with a small elderly population. This is likely to be somewhere late in Stage 3 or early Stage 4 of the demographic transition model. However, the demographic dividend is not a permanent feature – typically it will last 30–40 years. Countries may be able to prosper as a result of the increased proportion of young adults in their population, increasing the size of the workforce and reducing the number of dependants. South Korea’s rapid demographic transition was a byproduct of two well-timed changes: population policies and socio-economic change that affected savings, investment and the role of women.

RESPONSEAssimilation1 Outline the benefits of a demographic dividend.

2 In which parts of the world have birth rates remained high?

3 Describe some of the successes in family planning programmes around the world.

4 In what ways is it possible to lower fertility and child mortality?

5 Suggest reasons why Ethiopia is unlikely to achieve a demographic dividend until 2030 at the earliest?

6 How did the demographic dividend enable the ‘Asian Tigers’ to industrialise?

7 What are the problems that follow a demographic dividend?

Evaluation

1 ‘The demographic dividend has the potential to transform countries economically.’ To what extent do you agree with this statement?

ANSWER PLAN

●● Introduce and define key terms such as demographic dividend, dependency ratio, ageing population, youthful population.

●● Outline the conditions needed for a demographic dividend – both demographic and socio-economic.

●● Show the benefits of a demographic dividend using examples of named countries or groups of countries, e.g. Korea, China, the Asian ‘Tigers’.

●● Give examples in which a demographic dividend might not occur – falling fertility without changes in socio-economic conditions. Examples might include Ethiopia and other countries in sub-Saharan Africa.

●● Summarise, stating your views on the subject.

2 Describe the main changes to Ethiopia’s population pyramid, as shown in Figure 2.

3 How do the data in Figure 3 help illustrate the concept of a demographic dividend for South Korea?

Extension1 Watch the Population Reference Bureau’s video on the demographic

dividend at http://www.prb.org/Multimedia/Video/2013/demographic-dividend-engage.aspx. This video gives an overview of a demographic dividend – what it is and what it takes to achieve it.

2 Study the pages at http://china.org.cn/business/2013–01/29/content_27821010.htm and http://english.peopledaily.com.cn/90778/8145883.html that deal with China’s demographic dividend. Outline the concerns of some people about the ‘end of the demographic dividend’ and the arguments of others who believe that worry about China’s demographic dividend is ‘unnecessary’.

3 Read the article ‘Is Rwanda set to reap the demographic dividend?’ at http://blogs.worldbank.org/africacan/is-rwanda-set-to-reap-the-demographic-dividend. What are the opportunities and threats to Rwanda as a result of its changing population characteristics?



http://www.prb.org/Multimedia/Video/2013/demographic-dividend-engage.aspx

http://www.prb.org/Multimedia/Video/2013/demographic-dividend-engage.aspx

http://china.org.cn/business/2013-01/29/content_27821010.htm

http://china.org.cn/business/2013-01/29/content_27821010.htm

http://english.peopledaily.com.cn/90778/8145883.html

http://english.peopledaily.com.cn/90778/8145883.html

http://blogs.worldbank.org/africacan/is-rwanda-set-to-reap-the-demographic-dividend

http://blogs.worldbank.org/africacan/is-rwanda-set-to-reap-the-demographic-dividend

Contributors

David Redfern (Editor) Paul Guinness David Holmes Garrett Nagle

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Population & Health

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Changing Cities• From London to Rio – the Olympic

legacy

• What future for the traditional high street?

• Johannesburg – a city of acute disparity

• Phoenix – urban growth in the American Southwest

• Smart cities – new forms of urban development

Development & Globalisation• Keeping up with the ‘jans’ and ‘stans’

• Delivering the MDGs to sub-Saharan Africa

• The rise of Indian TNCs

• The Arab Spring – a generation in waiting?

• The Southern Silk Road

Natural Hazards• Climate change and natural

hazards

• ‘Frankenstorm’ – the devastation of Hurricane Sandy

• The impacts of El Niño and La Niña

• The consequences of the Christchurch earthquake

• Tohoku 2011 – hope beyond the disaster?

Population & Health• Dengue fever – the next global

threat?

• NCDs in the developing world

• Exploring the 2011 Census

• Healthcare provision in the UK and USA

• The demographic dividend – a window of opportunity?

Population & Health

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