Future of health care threatened by declining population 

Declining fertility may help our damaged environments, but will create hugely complex social and economic problems and threaten health care as we know it, writes Dr Will Cairns in Part Two of this two-part series.

In Part One of this two-part series on population, I explored how our current low levels of fertility will cause the global human population to start to plummet before the end of this century. Within just several hundred years, our numbers will have fallen to as low as one billion, and possibly heading towards perhaps just 100 million people. This will have profound impacts on the complex interdependent systems that we humans have built up over the past couple of centuries, and particularly on health care.

For a sense of scale, consider China, where fertility is low (with a total fertility rate [TFR] of 1.2) and the projected rapid and ongoing population decline starts with a drop of about 40% from 1.4 billion to 800 million over the next 75 years to 2100 CE (here). Or India, with a younger population and a TFR of 2.0, where the population is expected to peak at 1.7 billion by 2060 and then drop by 200 million to 1.5 billion by 2100 CE.

Low fertility is not expected to be a transient phenomenon. Wherever women enjoy low childhood mortality, better education, improved financial security, slow but real gains in workplace equality, and growing empowerment, couples choose to have fewer children (here).

It seems highly unlikely that women, and their partners, would willingly go back to having large numbers of children simply to fulfill their community’s need to restore a better dependency ratio and fill low prestige, low wage jobs. And why would or should they?

A recent article in The New York Times explored the impact of China’s various efforts to encourage women to have more babies. Despite offers of cheaper housing, tax benefits and cash for kids from a command economy attempting to influence social choices, punitive measures imposed to keep couples together by discouraging divorce (perhaps a form of command fertility!) seem to be having the paradoxical effect of discouraging women from both marrying and having children.

The challenges posed by a shrinking and unbalanced population are already evident also in Japan (here) and Korea (here).

I will not explore the place of women in some religious sects, let alone Margaret Atwood’s dystopian novel (and television series) of women enslaved as child bearers – The Handmaid’s Tale.

Moving on, contemporary national and global economic systems are predicated on competition for profit, ongoing growth, and “free” markets. It is important to recognise, however, that much of the time they distribute their benefits inequitably in the interests of the rich and the powerful.

While most of us have not considered the challenges posed for such systems by a rapidly falling population, the conversation has begun. The International Monetary Fund found that,

“Long-term projections are inherently uncertain: relatively small changes in fertility, mortality, or migration rates can have a substantial impact on the course of age-related spending over the remainder of the century. Risks are especially acute with respect to fertility, which has declined much faster than expected. In this light, spending pressures could be even greater than typically assumed.”

Others have written about the broad economic issues and structural consequences of population decline, particularly what to expect for the remainder of this century to 2100 CE (here, here and here).

Some, expressing their concerns about the destructive environmental impact of our excessively large population, have touted the decline as a reprieve for the planet and speculated about the potential for better social outcomes from a smaller population (here).

When national populations halve in half of an average lifetime of 80 years, growth becomes impossible. National gross domestic product (GDP) must drop (even though individual average wealth and per capita GDP might seem to increase when the total asset and production pool is divided among a rapidly shrinking population). Certainly, some individuals will manage to exploit quirks and opportunities to temporarily swim against the tide, but whole economies will recede as consumer numbers decrease, demand and markets contract, manufacturing follows, and opportunities for profits shrink. All businesses whose activity relates to the size of their market (ie, mining, manufacturing, services and agriculture) will contract as the number of buyers, users and consumers falls, and they compete in a shrinking and disrupted global economy.

The population of a shrinking multigenerational community is unbalanced. When numbers are dropping due to low fertility in the context of a long/maximal lifespan, the generation of dependent children is smaller than the generation of their working adult parents, which in turn is smaller than that of their elderly dependent parents (plus the residuum of even their very old and frail parents) who remain alive because of modern health technology. Globally, not long after passing 2100 CE, there will be only about one person of working age for every dependent person (here).

The ever-shrinking pool of workers will be required to do all the work that maintains their complex technological societies. It is hard to imagine how, in a contracting economy, they could sustain the level of manufacturing and agriculture (albeit declining) to produce sufficient wealth to meet their own needs (as we now define them) and those of their children, as well as those of the similar number of non-working dependent older members of the community. The imbalance will persist for as long as the fertility remains lower than replacement and most people live long enough to approach their maximum possible lifespan.

Health care contributes to the productivity of the economy when it sustains or restores people to activity as children and younger adults.

While health care for the elderly fulfils our need to care for family and improves our community’s sense of wellbeing, modern life-prolonging treatments that do not restore independence consume resources (including workforce) and are not directly productive.

In many countries, most illness and the majority of all deaths (in Australia 88.7%) now occur in people over the age of 65 years. And, although many older people like me are healthy and independent, eventually almost every one of us now expects to receive the expensive technology and labour-intensive care that might delay our dying as we get older, as well as the often-prolonged period of high level personal care that we require if we do not die until we are very old.

It seems impossible that any shrinking community with a 1:1 dependency ratio could allocate sufficient resources to provide such care for all. Although increasing the age of retirement and altered tax regimes might have some impact, it would be insufficient for the scale of the challenge.

These realities will pose particularly difficult ethical dilemmas for shrinking communities.

The International Monetary Fund report entitled The fiscal consequences of shrinking populations states (p 21),

“There is no escape from reforming entitlements. In the more developed economies, one priority remains to limit the excessive growth of health care costs.”

The report does not suggest how this might be done.

The importation by wealthy nations of large numbers of workers for either low paid, low status or high paid, high skill jobs seems unlikely to be sustainable in the long term. Apart from current practice being ethically highly questionable (here, here and here), some nations where skilled workers (eg, in health care) are already in short supply may choose to limit departures to protect their own interests.

Many countries with low TFRs – China, India and Japan – simply do not attract inward migration.

The shrinking population will eventually bring relief to the housing crisis in those nations where housing is in short supply, although many Australians will not be happy to see the value of their principal asset dropping. In Japan, which has a TFR of 1.3 and a falling population in spite of recent modestly increased immigration (here), there are a large number of abandoned houses (here).

Meanwhile, China is dismantling the Ponzi-like (here and here) housing boom/bubble that emerged in response to government efforts to sustain economic growth through housing construction for a growing population. Now, as its population is starting to decline, China has suddenly found itself with vast numbers of unfinished homes and plunging real estate values.

Unemployment and underemployment are likely to become a non-issue given the dependency rate. On the other hand, the jobs that open up in service industries, particularly health care of the elderly, may not be those that younger people would prefer in a seller’s market.

The issues I have raised above are but a taste of the hugely complex task of managing the global contraction of the human population. Although our plummeting population may give some relief from the consequences of our disruption of the biosphere, it will pose a vast range of philosophical, geopolitical, economic and ethical challenges. It is a global issue and given our global interdependence, anything short of fully globalised response will be inadequate.

While we are often unable to imagine the long term consequences of our choices, make many mistakes, and are commonly slow to respond to the lessons of our poor decisions, we have come a long way in the past few hundred years because we have reaped the benefits of our curiosity, our intelligence and our ingenuity.

My concern is that our grudging responses to human-induced climate change and environmental degradation demonstrate that we are limited to behaviour that evolved in response to the circumstances of our past, and are incapable of acting as visionaries responding in the interests of our future.

If we default to our ingrained response of small-minded self-interest, we will simply collapse back into the small communities from which we emerged not so long ago, no doubt to repeat many of our failures yet again. Perhaps we will remain trapped on the roller-coaster ride of our deeply entrenched behaviour, condemned to go around and around, up and down, again and again, but only for as long as the Earth will accommodate us.

The challenge of our shrinking population offers us a unique opportunity to collaborate in the pursuit of a modus operandi for long term stability on this tiny blue dot in space. Failing to act in the long term interests of humanity as a whole will simply confirm that our so-called intelligence means little, and that we are not as clever or as wise as we like to think we are.

Dr Will Cairns has retired from clinical practice as a palliative medicine specialist.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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