The Demographics of Inequality
Life expectancy in India, in itself an important indicator of the country’s development, is tapering off: The rapid increase seen in previous years has come to a worrying halt, while the difference between individual regions can be as much as 10 years or more. A study by the Max Planck Institute for Demographic Research confirms this trend. Just like the country itself, India’s demographics reveal some striking inequalities.
Nandita Saikia, a demographer at the University of Delhi, is not one to give up easily - which is just as well, given the trouble in reaching her by telephone: the line crackles and hums, before breaking up entirely. Unlike her place of work at the Population Research Centre at the Institute of Economic Growth, which is at the forefront of technology. She maintains a steady stream of e-mails until finally a solution is found to the communications problem: a private mobile phone does the job. Nandita’s voice betrays her concerns: "India still has a long way to go."
As a demographer, her country’s development is close to her heart. Together with scientists Vladimir M. Shkolnikov and Domantas Jasilionis at the Max Planck Institute for Demographic Research (MPIDR) in Rostock and Faujdar Ram of the International Institute for Population Sciences in Mumbai, she has been calculating life expectancy in India with a previously unattained degree of accuracy - providing one of the most important indicators of the state of development on the subcontinent.
The results, published in the journal "Population Studies" (Saikia, N., Jasilionis, D., Ram, F., Shkolnikov, V. M. (2011). Trends and geographic differentials in mortality under age 60 in India. Population Studies, Vol.65(1), pp. 73-89.), reveal a conflicting picture: Between 1970 and 2004 life expectancy rose significantly - a sure sign that living standards and public health in India were generally benefiting from the country’s headlong progress. Then, suddenly in the mid-1990s the curve flattened out (Fig. 2). In some states, mortality rates are now stagnating. Is this a harbinger of future economic development in this vast country?
The details unearthed by the combined team of German and Indian scientists also raise some questions: There are massive variations in calculated life expectancy within the country, with differences of ten years and more between individual states. There is a yawning gap between urban and rural populations, and also - if not quite so pronounced - between men and women. Oddly, whereas in the rest of the world women live longer than men, in India the reverse is true, as the figures now prove. A unique situation?
Reliable data for an immense country
It is thanks to special data collection techniques and a particular method of calculating life expectancy that Nandita Saikia and her MPIDR colleagues were able to bring such differences to light. "To my knowledge, there is no other source capable of providing reliable and consistent mortality figures for India over an extended period of time that cover both the country as a whole and the principal states," says the study’s co-author, Domantas Jasilionis of the Demographic Data department in Rostock.
The team’s findings are also unique in that India's official statistics fail to provide figures of comparable quality. Not even the figures for life expectancy at birth calculated by the United Nations manage to achieve the required degree of accuracy, says Domantas Jasilionis: "For the elderly in particular, the underlying survey data is far too imprecise."
The fact that India has just completed its latest 2011 census is of little help, since the data collected is relatively simplistic, focusing for example on overall population figures for towns and districts, population densities, gender ratios and literacy rates. It is common knowledge that India is, in the meantime, home to 1.2 billion people. And that by 2020, the subcontinent is likely to overtake China as the world’s most populous country.
"However to calculate life expectancy with any reliability, far more data is required: A complete set of population statistics with reliable mortality figures for each annual cohort and each age group. The gigantic task of maintaining such a system with error-free data for every area of this enormous country has so far proven too great".
The Indian researcher brought data skills to the job
"We are now trying to fill the gap in our knowledge where life expectancy is concerned," says Nandita Saikia. When she arrived at the MPIDR in Rostock for the first time in the autumn of 2008 as a student at the International Max Planck Research School for Demography, she brought with her a knowledge of a special demographic data collection technique know as the "sample registration system." This system gathers population statistics for a sample of around six million Indians in every part of the country. Aided by the data experts in Rostock, in the years that followed Nandita analysed the statistics and found them to be excellent - if only up to the age of 60.
These data records are however not enough in themselves to calculate what most people understand by life expectancy - so-called "life expectancy at birth" (for women in Germany in 2009, this was 82.4 years). This indicated the age that a child born today would likely reach if mortality conditions were to remain the same for each age group as they currently are.
Instead, the researchers calculated a figure that leaves out the defective part of the sample statistics for India: a "limited (temporary) life expectancy" up to the age of 60. By definition, the figure cannot exceed 60 years. In fact, Indians on average are meanwhile living longer. But this average cannot be calculated with adequate certainty. Limited life expectancy, on the other hand, is a reliable value.
If the figure were to be exactly 60, that would mean that the entire population would live to be 60 years old. No population can manage that, but the developed countries are getting close: Between 2000 and 2004 women in Germany managed 59, which is the equivalent of 93 percent of all women reaching the age of 60. The limited life expectancy for Indian women is substantially lower at 50.3 years.
The days of catching up are gone
The difference underscores just how far India still lags behind Western countries, like Germany. However, the results achieved by Nandita Saikia and her MPIDR colleagues also show how steeply life expectancy on the subcontinent has risen since 1970: In the space of three decades, life expectancy for women in India increased by almost nine years, equal to more than 20 percent. The increase for German women, over the same period, was just less than two years, or three percent.
Whereas the small increases seen in Germany are normal for a developed country, India desperately needs to see significantly steeper rises. Germany is one of the international leaders among nations with low mortality rates, while on the United Nations’ list of 193 countries, India is in 145th place. Given that 60 years ago it languished in 160th place, the country clearly has made some substantial early progress. But since the mid-1990s, the days of catching up have come to an end. Still, at least the subcontinent has not slipped back down the rankings.
Nandita Saikia sees little consolation, however: "For India as a whole, the demographic indicators are all improving," she says. But the deciding question is: "Are we capable of eliminating the glaring inequalities within the country?" Her limited life expectancy calculations leave no doubt as to the scale of these inequalities. Between 2000 and 2004, limited life expectancy for men varied by up to eight years between the different regions, while for women the variation was as much as eleven years.
Despite the fact that statistically, the regional gap has halved in the past 30 years, it remains great. By comparison, life expectancy at birth for men currently varies between Germany’s regional states by around three -and-a-half years, and for women by a little over two years.
Indian citizens in the northeast die younger
Nandita Saikia believes that the inequalities are greater even than a simple regional comparison suggests. For example, women living in rural Madhya Pradesh live an average of 21 years less than their counterparts in a city in Kerala. "If we were able to calculate life expectancy not just by regions, but by place of residence and socio-economic factors, such as material prosperity, religion and caste, then the gulf would be even wider," says the Indian researcher.
Nor is the regional pattern evident from her data accurate enough as yet for her scientific aspirations. It confirms the findings of previous studies, namely that life expectancy tends to be greater in the more prosperous and educated southwest of India than in the northeast (Fig. 3). However, some ambiguities remain: for example, limited life expectancy in the northern regions of Punjab and Himachal Pradesh is well above the average for other northern states.
There would be many more such irregularities, Nandita Saikia suspects, if life expectancy could be calculated not just for regions but for individual districts. The uniform image presented by the regional statistics might then be replaced by a complex patchwork.
And yet it is precisely this complexity that must be revealed and studied if it is to be specifically determined where the deficiencies lie in India’s development. "We need local data," says Nandita Saikia, "if we are to find out why progress is stagnating in so many places, despite government investment in aid and development programs."
Women are the key to progress
Child mortality in India is particularly serious: The primary reason why life expectancy rose steadily through the 1990s was because mortality rates among 0 to 15 year-olds declined noticeably across the board (Fig. 2). Then, at that point, the growth in limited life expectancy ceased, because the country was scarcely able to reduce child mortality any further. In three out of 16 regions the rate began to climb again, while in three more it remained static.
"Without fundamental improvements in healthcare, especially for women in childbirth, we will not make the necessary progress in reducing child mortality," Nandita Saikia believes. In her view, women are the key to continuing development. Where women enjoy greater autonomy and are better educated, birth control is more effective and both birth rates and child mortality rates tend to decline.
India still has a long way to go. Widespread patriarchal traditions and laws stand in the way of progress where female autonomy is concerned. The fact that limited life expectancy among India’s women is lower than for men reflects the inequality between genders, as well as the alarming abortion rates for female fetuses and the high level of puerperal mortality. A woman’s life in India is worth less than the life of a man - another reason why 1.8 million Indian children die each year before reaching the age of five.
UNICEF, too, is pressing for greater commitment in the fight against child mortality. The organization records, in its latest survey, that out of every 1000 newborn children in India, 66 die before reaching the age of five (figures for 2009; comparative number for Germany: four per thousand). In this respect, India continues to lag behind the rest of the world, though the percentage rate has almost halved since 1990. The trend is positive - if not ubiquitous.
This also means that further substantial growth in life expectancy will be dependent upon an increase in the survival rate among adults. Where child mortality is already low, improvements in the percentage rate will no longer be reflected in appreciable increases in life expectancy.
India is in the midst of what is described as an "epidemiological transition": Efforts to combat infectious diseases such as diarrhea, pneumonia, tuberculosis and malaria which, in the past, have claimed many children's lives, have already proved successful in many states, thanks to simple precautions such as better hygiene, clean water, vaccinations and medication.
The diseases of modern civilization are on the increase
"Now the country is beginning to tackle the problems that afflict its adults," says Nandita Saikia. There has been a noticeable increase in particular in chronic illnesses, such as cardiovascular disease, as well as the health problems resulting from an unhealthy lifestyle with too little physical activity, poor eating habits and above all smoking. It is estimated that one in five deaths among Indian men aged between 30 and 69 is attributable to the use of tobacco. As yet, India has found no remedy to the new ills that accompany civilization. However, if it does not do so, there will be no improvement in its life expectancy.
No matter how paradoxical it may sound, it is a sign of progress that in India, as in many other countries at the same stage of development, these new diseases are now spreading. Is India therefore about to step up to the same developmental stage as the rich countries of the world in which smoking, obesity and chronic diseases have, in the meantime, become the dominant challenges to health policy?
For Nandita Saikia, this is a little too simplistic. Her homeland is too diverse. "In India you will find everything," says the demographer. While some regions have already passed the stage of epidemiological transition, in others child mortality is still as high as in the poorest countries of Africa. The battle to improve life expectancy in India is still being fought on all fronts.