An uncomfortable pause

by Kevin Boehnke

Main photo from

Over the holidays, I was walking on the beach in California with my dad and brothers. As the Boehnke clan ambled across the beach, we ruminated about the public health implications of various scientific discoveries and policies, including the malaria vaccine, HIV vaccine, water quality improvements, and antibiotics (yes, I have a really, really exciting family). While agreeing that these discoveries were crucial for improving the quality of life for humans in general, we stumbled on a distressing question: If all of these policies are successful, what would happen to all of those extra people (who would otherwise be deceased) living on the planet? It is common for people to have many children in places with high infant mortality rates, but now instead of 1 or 2 of 8 children surviving, there would be more like 4 or 5.

In the past, as the population increased, there were more jobs available, more land available, and a great deal of natural resources to exploit. Health interventions typically went hand in hand with growing wealth; as workers increased in number and clout, they demanded better working conditions, wages, and health care. Most of this growth happened internally, leading to a more gradual and concurrent progression of increases in wealth and health. However, many of the public health interventions in the developing world today are funded and implemented by foreign sources with a sole focus on improving public health, so providing for public health isn’t always matched with an increasing national wealth.

File:1973 Delhi Slum.jpg
Delhi Slum. Source: Wikimedia commons

Would there be opportunities available for this increased population, or would they continue to swell the already massive slums surrounding city centers worldwide? Globally, there are high rates of unemployment, but especially so in the developing world where the most lives would be saved by interventions like the ones we were discussing. These countries typically have poor infrastructure, so it can be difficult to get around the country to places with better opportunities. To further complicate things, there is limited land for agriculture and widespread financial and political corruption. An increased number of humans would exacerbate these already immense challenges. For example, in Collapse, Jared Diamond’s book on the rise and fall of  civilizations, Diamond suggests that one of the underlying reasons for the Rwandan genocide was a large population boom (440% increase over 55 years) concurrent with a decrease in job and land availability. Clearly, genocide is an extreme case, but a population boom increases the likelihood of famine and communicable disease.

File:Children affected by famine in Berdyansk, Ukraine - 1922.jpg

Children affected by famine in Berdyansk Ukraine, 1922. From: Wikimedia commons

If we are successful in pursuing public health problems in low-income countries without simultaneously increasing opportunities and improving infrastructure, are we potentially setting the scale for future famine (or less likely, genocide) events? None of us really had a satisfying answer to that, but after chewing on that thought for a while, we came up with three potential options:

  1. Use institutions like the International Monetary Fund (IMF) and the World Bank to pour money into massive infrastructure projects, business opportunities, and education.
  2. Start an initiative to empower families globally, with a focus on family planning. This would be an education-based program that would also provide birth control to women.
  3. Couple wide-scale public health interventions with grassroot economic opportunities like micro-finance.

Of course, all of these potential interventions are enormously difficult. Number 1 is very expensive, and historically large infrastructure projects funded by outside sources have not always ended well (for instance, in Jamaica and South Africa). Number 2 is potentially even more challenging than number 1. People don’t like it when outsiders come and tell them how to live their lives or to change their moral and cultural standards: we’ve seen how that works out in the past in countries like Iraq. Further, with the negative global views towards interventionist foreign policy, this option might not be considered trustworthy. To me, number 3 seems the most possible to implement, but it would require a systemic integrated assessment approach: a concerted effort to connect multiple disciplines (economics, public health, finance, urban planning, etc…) to policy makers and community members.

Clearly, these aren’t the only factors at play, nor is this list exhaustive. If large-scale public health interventions succeed and the workforce grows larger and healthier, then more people will likely start their own businesses, become more literate, have higher income, and create opportunities for people within their communities. This larger, cheaper labor force will also attract foreign investment for factory jobs (e.g. clothes, textiles). Historically, this has typically happened organically as the healthy population increases (e.g. South Korea). These forces will likely be occurring simultaneously as the public health interventions roll on, and I want to acknowledge that. However, my point is that I am unsure of whether they will be enough to keep up with the large population growth.

To be sure, our discussion of these potential problems did not diminish our hope that such interventions would succeed (individually or in combination with each other). However, it did illustrate the systemic nature of how societal problems are tied together into a complex web; pulling at one thread causes the rest of the web to shift and change as well.

So what do we do? How would you handle this situation? Are we doomed to fail? Or will human innovation help tackle this most challenging of problems?


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  • Ashraf, Nava, Günther Fink, and David N. Weil. Evaluating the effects of large scale health interventions in developing countries: The Zambian Malaria Initiative. No. w16069. National Bureau of Economic Research, 2010. link
  • Lund, Katie, et al. “Benefits of using Integrated Assessment to address sustainability challenges.” Journal of Environmental Studies and Sciences 1.4 (2011): 289-295. DOI
  • Amexo, Mark, et al. “Malaria misdiagnosis: effects on the poor and vulnerable.”The Lancet 364.9448 (2004): 1896-1898. DOI