Conclusion and outlook

The sections above have documented how advances in agricultural efficiency after 1700 allowed the societies of Europe and North America to expand and improve their diets by an unprecedented degree. The rise in agricultural efficiency set off a self-reinforcing cycle of improvements in nutrition and gains in labor productivity, leading to a substantial increase in per capita output, which has come to be known as “modern economic growth”. It was shown how the initial increase in agricultural. Efficiency was magnified by providing the population with enough additional calories to boost the number of acres cultivated per hour, annual hours worked, and the labor force participation rate. Based on the notion that variations in the size of individuals have been a principal mechanism in equilibrating the population with the food supply, improved net nutrition has been identified as the primary long-term determinant of the sharp increase in the number of disability-free years of life. The gains in longevity, in turn, have created an incentive for individuals to maintain and upgrade skills and personal health. This line of argument underpins the prediction that the conquest of malnutrition may continue to raise the productivity and innovative capacity of the labor force in the West. The time series of various components of agricultural output per capita in the United States since World War II has been analyzed and combined with the data presented, the following conclusions emerge for the advanced economies of Western Europe and North America.

•Output per acre cultivated has been increasing throughout the period under study.

•Acres cultivated per hour have been increasing throughout this period, first because human energy available for work increased, then because animal and inanimate power complemented and eventually substituted for human energy.

•Annual hours worked per agricultural worker increased at first, as more calories became available for discretionary use, but have been declining recently and are expected to continue to decline.

•The rise in agricultural labor productivity has permitted the number of agricultural workers per inhabitant to decline without lowering the amount of calories available per person.

•The declining share of agricultural workers in the labor force permitted other sectors of the economy to grow, thus greatly diversifying and expanding the range of nonagricultural goods and services. The recent reversal of some key trends in energy intensity of work and labor force participation rates suggests that the economic and epidemiologic consequences from the unprecedented improvement of human nutrition in the rich countries are still being played out. Up to World War II the energy intensity and quantity of work in Europe was limited by the availability of food per capita. Since then, however, caloric intake has not only matched individual caloric requirements but tends to exceed calorie expenditure in an increasing portion of the population. One indicator of this tendency is the growing prevalence of obese adults in the United States, which between 1960 and 1994 increased from 13.3% to 23.3% (National Center for Health Statistics, 2001). This trend is compounded by the fact that the progressive substitution of human energy by inanimate power and the concomitant expansion of sedentary work have led to a gradual reduction of calories expended per hour worked. The continued increase in agricultural output per person coupled with lower energy requirements on the job. may portend two, not mutually exclusive, scenarios for the next stage of the nutrition transition in the world’s richest countries.

1. As more and more people work in occupations that do not place high demands on calorie supply, they may decide to increase energy spent during leisure hours. In addition, further gains in stature and weight will raise the calories needed for maintenance.

2. Alternatively, workers may decide to reduce their overall calorie intake to bring it into line with the decreased amounts of calories at work. Although expenditure on food may not decline in absolute terms, consumers may opt to substitute increasingly away from quantity toward quality of calories and become choosier regarding those calories that they decide to purchase and ingest. To the extent that pressure for advances in productivity and greater per capita supply of calories wanes in rich countries, it is conceivable that forms of agriculture that are less productive in calories will gain popularity to accommodate other criteria in the selection of agricultural products and processes. For example, organic agriculture, which renounces the use of certain herbicides, pesticides and fertilizers, accepts lower yields per acre in order to reduce environmental hazards. Similarly, a shift in consumer preferences may prompt the cultivation of crops that sell at a premium but require more care or are less nutritious, thus lowering the amount of calories per hour worked. The situation is very different in poor countries where more than 800 million people are chronically undernourished (FAO, 1999). Progress in agricultural productivity remains the focus of most programs aimed at raising the per capita supply of calories and other vital nutrients. Yet even in countries where average food consumption is deemed adequate, an unequal distribution of income may effectively preclude the poorest parts of the population from obtaining sufficient calories, as was shown for late eighteenth-century England and France. Recent data from developing countries confirm the association of greater income inequality with increased food insecurity and smaller body size (Steckel, 1995; Shapouri and Rosen, 1999). Whatever the approach to alleviating chronic hunger in developing countries, improving the food supply could unlock the short-term and long-term effects of better nutrition on labor productivity that have had such a lasting impact on the growth trajectories of Europe and North America.

Read More

Population growth

After decades of accelerating growth the global rate of population increase peaked at just over 2% a year during the late 1960s, and gradual declines of fertilities also speeded up the arrival of the absolute peak, at about 86 million people a year, during the latter half of the 1980s and the annual increase was down to 77 million people by the year 2000 (UN, 1998, 2001). As a result population projections issued during the 1990s had repeatedly lowered the long-term global forecasts for the next 50 years. The medium version of the 1998 revision envisaged just 8.9 billion people by the year 2050, down from 9.4 billion forecast in 1996, and 9.8 billion in the 1994 revisions (UN, 1998). And the high variant in 1998 was well below 12 billion people by the year 2050, in line with increasing indications that yet another doubling of human population to 12 billion people is unlikely (Lutzet al., 2001).

12

11                                                                                                 High

10                                                                                                 Medium

9

8                                                                                                   Low

7

6

5

4

3

2

1

0

1950 2000 2050

Figure 3.5

The UN’s latest long-term projections of global population growth (UN, 2001).

But the latest UN (2001) projection raised its medium 2050 forecast to 9.3 billion (Fig. 3.5). The difference of some 400 million people above the 1998 forecast is explained largely by the assumption of somewhat higher fertilities for the 16 develop-ing countries whose fertility has not, so far, shown any sustained decline. There is a different kind of uncertainty concerning the rich world’s population. Without substan-tial immigration it would start declining as a whole within a few years and by the year 2050 it would be barely above one billion, 20% below its current total (as already noted, UNO’s and FAO’s definitions of developed and developing populations are not identical: they differ by about 100 million people). With continued immigration it would be more or less stable, reaching 1.8 billion in 50 years. Even then many European nations and Japan would experience substantial population declines. Russia’s case is particularly noteworthy, as it now appears that there is little chance of revers-ing its population decline brought on by economic deprivation, social disintegration and exceptionally high rates of alcoholism. As a result, Russia may have 30 million fewer people by the year 2050. By that time the US population will, most likely, approach 340 million.

Inherent uncertainties of long-range forecasting aside, there is no doubt that virtu-ally all the net population increase of the next two generations will take place in today’s developing world, and that the global population of 2050 will, most likely, be 50% larger than it is today. Moreover, most of the additional population growth of some 2.8–3.2 billion people will be concentrated in nations whose agricultural resources, although absolutely large, are already relatively limited. Brazil is the only modernizing populous country (i.e., with more than 100 million people) with abundant reserves of arable land and water (Fig. 3.6). Fifty years from now India, after adding nearly 600 million people, would have a population more than 50% larger than today and would be, with just over 1.5 billion, the world’s most populous country, with China a very close second. Three African and two Asian countries would add more than 100 million people each: Nigeria, Pakistan, Indonesia, Congo, and Ethiopia. As a group these nations would have to increase their food harvests by two-thirds merely to maintain their existing, and in many respects inadequate, diets.

0.5

0.4

            Nigeria

0.3                         Brazil

            Pakistan

0.2

                                                                                 India

                        Indonesia

0.1

            Bangladesh China

0.0

0 200 400 600 800 1000 1200

Population (million)

Figure 3.6

Brazil and Nigeria are the only two developing countries with considerable reserves of potentially arable land; in all other populous modernizing countries future increases of food output will have to come from further intensification of cropping. Plotted from data in FAO (2001).

Only Congo and Nigeria have relatively low population density per hectare of cul-tivated farmland and large untapped agricultural potential. At the same time, the late 20th-century record of these two countries makes it hard to imagine that they will be the ones to mobilize their resources effectively and to evolve a civil society deter-mined to bring widespread economic advances. China and Indonesia are already the paragons of highly intensive cropping, and India and Pakistan are close behind. But, some poorly informed and sensationalized judgments notwithstanding (Brown, 1995), there is more hope for China’s farming than is the case with perhaps any other large populous country (Smil, 1995). As already noted, China has about 50% more farmland than has been officially acknowledged (which means that its actual average yields are substantially lower than reported) and it has many opportunities for increas- ing the productivity of its cropping (Smil, 1999c). India’s situation, though undoubt-edly highly challenging, appears to be more hopeful than the Indonesian or Pakistani prospect. As for Ethiopia, natural aridity affects large parts of its territory and already limits its food production capacity.

Read More

Institutions

Institutions

 When the General Agreement on Tariffs and Trade (GATT) was signed by over 100 countries in 1994, it was to have profound direct and indirect implications for public health in

Health

Sciences

                                                                           Culture

                                                                                                        Urban life Plants

                        Rural life

Climate

                                                                                                        Light

Earth Ecology Animals Biodiversity

                                                                           Water

Figure 4.4

Food’s impact on health: the complex model (from Waltner-Troews and Lang, 2000) with permission.

general, and for food and agriculture in particular. It created the immensely powerful World Trade Organization (WTO) which not only monitors trade rules but runs a system of arbitration which is de facto a new jurisprudence. This mattered for public health for a number of reasons.

The institutions through which public health has expressed its views in the post-war period have been quietly marginalized (Labonte, 1998). A new system of world governance, much commented on by its non-governmental organization (NGO) critics, is emerging in parallel to, and more powerful than, the formerly more democratic institutions of the United Nations (Navarro, 1999). The WTO (or the World Bank) is more significant in framing the conditions for public health than the WHO (Banerji, 1999). The WHO is informed by a World Health Assembly, yet there is no parallel citizen’s voice for the WTO. Economically, there is no contest as to which is more significant, the UN system or the new trade system.

The GATT is a key, if not the key, structure in the architecture of the new era of globalization. Within the many hundreds of pages of the full GATT agreement, public health barely registers, except when implied as a threat to free trade. A fear that health is a fig-leaf for protectionism stalks the neoliberal halls, whereas to proponents of public health, the notion of “protection”, like prevention, carries positive rather than negative connotations. In the GATT’s Agreement on Agriculture much effort was put into ensuring that national governments cannot set food standards or restrict entry of foods unless they have “sound scientific” justification. This seems reasonable, although in practice subject to subjective interpretation and commercial pressures.

Research conducted in 1991–93, before the 1994 GATT was signed, suggested that Codex was not in a fit democratic state to carry public confidence about its processes (Avery et al ., 1993). Codex is a large system of around 20 committees, which has many participants at meetings around the world. These working parties are usually hosted by rich countries and meet over two years and make recommendations to the bi-annual full meeting of the Codex Commission. Over the full 1991–93 cycle of meetings there were a total of 2758 participants. Codex is theoretically a meeting of governments but the study found that nearly a quarter of participants were from large international companies – the same for whose products were being set standards. Reviewing a full two-year cycle of Codex meetings, the

Cracking the Codex study found that:

• 104 countries participated, as did over 100 of the largest multinational food and agrochemical companies;

•The vast majority (96%) of nongovernmental participants represented industry;

• There were 26 representatives from public interest groups compared to 662 industry representatives;

• Nestlé, the largest food company in the world, sent over 30 representatives to all Codex committee meetings combined, more than most countries;

• Most representation came from rich, Northern countries: over 60% came from Europe and North America with the poor countries of the South dramatically under represented – only 7% from Africa and 10% from Latin America;

• Of the participants on the working group on standards for food additives and contaminants, 39% represented Transnational Corporations (TNCs) or industry federations, including 61 representatives from the largest food and agrochemical companies in the world;

• Of the 374 participants on the committee on pesticide residue levels, 75 repre- sented multinational agrochemical and food corporations, 34 from the world’s top 20 agrochemical companies; only 80 participants represented the interests of developing countries;

• The USA sent more representatives to Codex than any other country (50% of them representing industry) and almost twice as many as the entire continent of Africa.

Following the publication of this report and despite requests to “clean up” this inadequacy, the GATT secretariat declined to act. In subsequent years, officials and companies became sensitive to these criticisms, which have been pursued by the consumers’ movement. Some countries now hold tripartite national premeetings with industry, consumers, and government officials before going to Codex meetings. However, this left practice at the Codex meetings themselves unchanged. One review in 1997 concluded that little has changed (McCrea, 1997). At the 1997 Codex food labeling committee, for instance, the US delegation comprised eight government officials, three from NGOs and ten from industry. Reform is now, happily, beginning, but why so late?

Particularly sensitive is the issue of scientific judgment. The GATT stipulated that disputes would be arbitrated on grounds of “sound science”, yet consumer groups argue that science is not the only salient feature, nor indeed is science quite the straightforward arbiter it is assumed to be. Whose is the research? Who funded it? Is it publicly available? What questions framed the analysis? The argument between the USA and the EU over hormone use in meat fattening illustrates the sensitivity of the issue. Since the early 1980s, the EU has implemented a ban on the use of hormones. This was con-tested by the US, keen to sell its beef in Europe’s rich markets. The dispute was referred to Codex and the long-awaited WTO decision was announced in early 1998. Both the US and EU claimed vindication of their positions (EC, 1998; USTR, 1998). The EU’s Scientific Committee on Veterinary Measures then argued that further studies suggested scientific evidence warranting a continued ban (European Commission, 1999).

 The food trade issue is now particularly sensitive. For the last few years there has been a steady stream of high profile cases where food-exporting nations fight over the right to export surpluses to each other and to markets they deem their own. There have been wars over lamb between Australia and New Zealand and the USA (International Centre for Trade and Sustainable Development, 1999); over beef hormones between the EU and USA; over genetically modified foods between the USA and many countries but especially the EU. The notion that food security stems from growing most of one’s food within one’s country (what used to be called self-reliance) is being eroded by the notion that security stems from being able to purchase food on the open world markets (WHO-Europe, 1995).

Food security is a concern for most developing country governments whereas rich countries are more troubled by consumer-driven food safety issues. As the WHO Regional Office for Europe’s (1999) Food and Nutrition Plan recognizes, from a public health perspective, both are important and both re ect changes in methods of production and distribution and in the food system (Tansey and Worsley, 1995; Lang, 1997). The Norwegian Government was rare among rich nations in openly criticizing the drift of the new GATT talks. It should know. Its citizens voted in the early 1990s against joining the EU, in part from hostility to the Common Agricultural Policy undermining the national nutrition and food policy in place since 1976 (Royal Norwegian Ministry of Agriculture, 1976). Yet Norway by signing onto the 1994 GATT began to erode exactly the very same national policy.

In a paper prepared in June 1999, Norway laid down a clear policy challenge: food security is too important to be left to the vagaries of trade (Royal Ministry of Agriculture, 1999). Under the Plan of Action agreed at the 1996 World Food Summit, as at the earlier 1992 International Conference on Nutrition, Governments agreed they have a moral responsibility to ensure their citizens have adequate food, are free from hunger and achieve food security (World Food Summit, 1996). The GATT perspective favors the market approach to food security. Tacitly, it argues that the cheapest food is best. The new public health perspective suggests that the West’s food revolution has intensified food production such that when food is cheap, other costs are being externalized onto the environment (Lang, 1999b). In this intellectual context, Norway’s position was pioneering. It argued that the new Round should agree on rules to safeguard national food security. When wheat or maize prices can rise by 50% in just two years, as happened in 1993–95, reliance on being able to buy one’s food in the world marketplace is a form of security only open to the af uent. (Norway, as a small population with immense oil wealth is ironically one such country.) What are the poor to do in such circumstances: tighten their belts? As Sen (1981b, 1997) and others have shown, hunger follows poor purchasing power and is not necessarily a function of food availability.

The new WTO structures are designed to facilitate cross-border economic activity and to reduce national control over capital  ows, competition and even cultural control. In the age of the internet, information knows few boundaries yet vast new corporations are emerging which dominate almost everything humans do or consume. The irony about the new GATT is that it is based upon the free trade model of globalization just when evidence about its negative effects is mounting up. According to the tenth annual UN Human Development Report, the richest 20% of the world now account for 86% of world GDP, while the poorest 20% have just 1% (UNDP, 1999); 200 of the world’s richest people have doubled their net worth in the last four years. The richest three people in the world have assets greater than the combined Gross National Product of all the least developed countries in the world, 600 million people. There is little chance of health for all in such a socially divided world.

Another reason for public health involvement in trade talks and debate concerns the work of public health monitoring itself. Public health action has to be based on a good understanding of the real world. Perspective is in order. Postwar development has brought astonishing gains for billions of people, but equally, as the Human Development Report documents, the scale of contemporary inequality and poor healthcare defies sanity. The Human Development Report itself came into existence because a decade ago, UN administrators, social scientists, and politicians were critical of the convention of measuring development through indicators such as Gross Domestic or National Product. They disguise intranational inequalities and fail to convey the quality of life issues. The Human Development Index was created to fill this gap. The Human Development Report shows that 80 countries have incomes lower today than a decade ago; 1.3 billion people, over a fifth of humanity, exist on less than US$1 per day. However it is measured, the gap between the richest and poorest is widening. In 1960, the gap between the richest fifth and the poorest fifth was 30:1. In 1990 it was 60:1. In 1997 it was 74:1 (UNDP, 1999). In this context, it is clear that epidemiologists as much as physicians and health activists have to ask themselves how their work does or does not confront this obscene accrual of wealth and power. And does the nutrition transition call for new health indicators? Almost certainly, yes!

The Human Development Report , however, argued that globalization is unstoppable and that all good people can do is try to give it “development with a human face”. It is true that proponents of unfettered free trade are more defensive than in 1987–94. Faced by growing opposition and the sheer weight of evidence of harm, the architects of inequalities in health now plead that we should still trust them and that (their version of) growth must continue by a different path (Wolf, 1999). Inequalities may be bad, they admit, but now is the time to target resources on the poor. We should ignore, they imply, the accrual of power by the rich as they are the motor force of the new global economy.

Read More

Demographic Trends

Hania Zlotnik

Over the past four centuries the population of the world has increased tenfold, rising from about 580 million persons in 1600 to slightly over six billion in 2000 (Biraben,1979; United Nations, 2001a). Most of that growth occurred during the 20th century when the population nearly quadrupled (Fig. 5.1). Thus, whereas it took three centuries – from 1600 to 1900 – for the population to increase from 0.6 billion to 1.6 billion, between 1900 and 2000 a further 4.4 billion persons were added to the world population. Such rapid population growth, unprecedented in human history, resulted largely from the major reductions of mortality that occurred during the 20^th century. Between 1900 and 2000, life expectancy at the world level nearly doubled, reaching 65.5 years by the end of the century. Almost universally mortality reductions preceded changes in fertility. In populations where mortality had been traditionally high, women had to bear large numbers of children to ensure that enough of them survived to adulthood. As mortality declined, populations did not immediately adjust their fertility levels to match the reduced risks of death. As a result, populations grew rapidly when high fertility persisted even as mortality declined. The more developed countries of today were the first to experience sustained declines of mortality. Starting in the 18th century, better hygiene and improving standards of living contributed to reduce mortality rates in those countries. Between 1750 and 1850, for instance, life expectancy in a number of European countries increased from 25 years to 35 years (Vallin, 1989) and during the 19th century, as mortality reductions accelerated, a widespread fertility decline began as well. Although even for Europe the data available on fertility trends over the 19th century are partial, it would appear that fertility in the continent declined from about 5–5.5 births per woman in the early part of the 19th century to about four children per woman in the early part of the 20th century (Clark, 1968). The process whereby reductions of mortality are followed by reductions of fertility sufficient to ensure that overall population growth remains low is known as the demo-graphic transition. During the 20th century, most developing countries embarked on the demographic transition. Indeed, with the discovery of antibiotics and other means

The views and opinions expressed in this chapter are those of the author and do not necessarily represent those of the United Nations.

The Nutrition Transition

Copyright © 2002 Elsevier Science Ltd

ISBN: 0-12-153654-8

All rights of reproduction in any form reserved

10.000

9.000

8.000

7.000

6.000

5.000

4.000

3.000

2.000

1.000

0.000

400 200 0 200 400 600 800 1000 1200 1400 1600 1800 2000

                                                                                              Year

Figure 5.1

Long-term population increase, _BC400 to 2000_AD.

to combat the spread of the infectious diseases endemic in developing countries, rapid reductions of mortality were achieved in those countries after 1945–1950. As in the more developed countries earlier, the continuation of high fertility as mortality declined gave rise to very rapid population growth, but fertility reductions in the developing world have been occurring more rapidly than in the more developed countries. The availability of modern contraceptives has facilitated such developments. By the end of the 20th century, most developing countries had initiated the transition to lower fertility. According to United Nations (2001a) estimates, by 1995–2000 only 16 developing countries had not yet shown signs of a fertility reduction and they comprised just 3% of the world’s population. Not only did the 20th century witness a rapid rise of population but, in addition, it saw the distribution of the population between rural and urban areas change dramatically. Indeed, although the existence of populous cities with urban attributes dates back several centuries if not millennia depending on the region under consideration, the vast majority of the world’s population has lived in rural settings during most of human history. Even as late as 1800, only 5% of the world population lived in urban areas and by 1900 that proportion had increased to just over 13% (United Nations, 1980). But over the course of the 20th century the proportion urban more than tripled, reaching 47% by 2000 (Fig. 5.2). The process of widespread urbanization started earlier in the more developed regions than in the developing world. Already by 1900 one out of every four inhabitants of more developed countries was an urban dweller whereas in the developing world the equivalent proportion was one in fifteen. Although levels of urbanization have risen markedly in developing countries, by 2000 less-developed regions are still about half as urbanized as more-developed regions. Thus, whereas 76% of the population of the latter lives in cities, just 40% of the population of less-developed countries is made of urban dwellers. This chapter describes in more detail the evolution of the size and growth of the world population and the dynamics of the process of urbanization in the major regions

90

80

70

60

50

40

30

20

10

0

1800 1825 1850 1875 1900 1925 1950 1975 2000 2025

                                                                              Year

World Less-developed regions More-developed regions Series 4

Figure 5.2

Percentage of population in urban areas, 1800–2030.

of the world since 1950. It also discusses future prospects and their implications. The data presented were derived from the 2000 Revision of estimates and projections of national populations prepared by the United Nations Population Division (United Nations, 2001a,b) and from the 1999 Revision of World Urbanization Prospects (United Nations, 2001c). To ensure consistency between the two sets of data, estimates and projections of the urban and rural populations were derived using the national populations produced by the 2000 Revision and the proportions residing in urban areas as estimated and projected by the 1999 Revision of World Urbanization Prospects.

Read More