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938 www.thelancet.com  Vol 383 March 15, 2014

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Offl ine: The laws of stupidity

In a meeting last week on the future of women’s and

children’s health, one respected public health scientist

warned about the population doubling time in Africa. She

estimated it to be around 20 years. (In fact, according to

the UN Population Division, the population doubling time

for sub-Saharan Africa is about 35 years. Still, her general

point remains valid.) She argued that many of the gains in

children’s health won over the past decade would be lost

if this scenario of dramatic population expansion came to

pass. Her view is widely held in the health community. And

our solution—rapid scale-up of family planning services—

has received endorsement and support from experts

and donors alike. Family Planning 2020 is a movement

to provide contraceptive services to an additional

120 million women worldwide. This momentum around

family planning is welcome, especially if the definition of

family planning covers a full range of reproductive health

services. But is access to contraception really the answer

to Africa’s—the world’s—demographic challenge? This

simplistic technical approach illustrates so much of what

is wrong with global health today.

*

In a second-hand bookshop recently, I came across a

worn £2·99 copy of Carlo Cipolla’s now out-of-print

volume, The Economic History of World Population. First

published in 1962, his short book was reprinted at least

seven times (my copy dates from 1979). Cipolla was an

Italian economist born in Pavia in 1922. He died in 2000.

His argument is worth summarising as we think about

the health of our planet and its human populations.

Cipolla thought globally. In the preface to the first edition

of his book, he wrote: “Today we have to adjust ourselves

and our ways of thinking to a global point of view” (his

italics). He began by describing the two great revolutions

of human civilisation—agricultural and industrial. Each

launched a “new story” for the human species. Industrial

revolutions in the world’s poorest nations are “their

great hope” to achieve good health, the beginning of

their new story. But one antagonistic force challenging

such an optimistic view is “the population problem”,

which we continue to this day to see as a threat to

sustainable development. Another is the now widely

accepted paradox that technical progress has also cast “a

sinister shadow on the future of industrial societies”. An

aspect of technical progress that Cipolla found especially

“appalling” was our “humanitarian urge to give medical

assistance to societies that basically are still agricultural”.

By doing so we only fuel the “demographic explosion”.

Cipolla was worried about our complacent approach

to this menace. He emphasised our over-confidence,

our belief that we can easily absorb the consequences

of population pressure—not only embracing the

demographic dividend of an expanded labour force, but

also facing up to a source of new epidemics, intensifying

pollution, and disruptive political and economic crises. Yet

these risks, so prevalent in our conversations today, are

marginal to an even greater threat identified by Cipolla.

*

We neglect the “drastic cultural and social changes” that

accompany shifts in economic organisation, he claimed.

In “the excitement of our progress” (the rapid “technical

progress” of our species), we do not stop to ask “how

much [have we ourselves] improved in quality?” The

danger is that as our populations grow, the marginal

value of each person will diminish “and the dignity of

human life deteriorates correspondingly”. In addition

to the technical progress we justly celebrate, we must

also pay attention to our “ethical and cultural values and

standards”. What we need “is not merely more technical

knowledge”, but greater investment in the qualitative

improvement of our species—how we think about and

behave towards one another. Thankfully, another book

by Carlo Cipolla remains in print—The Basic Laws of Human

Stupidity. His Third (and Golden) Basic Law is that, “A

stupid person is a person who causes losses to another

person or to a group of persons while himself deriving no

gain and even possibly incurring losses.” Our attitudes to

human population growth fulfil Cipolla’s Third Law. Our

advocacy of technical knowledge—expanded coverage of

family planning services—has paid too much attention

to life’s quantities and too little to its qualities. “There is

nothing more dangerous than technical knowledge when

unaccompanied by respect for human life and human

values”, writes Cipolla in his Economic History. Look at the

world today, and one sees a scandalous absence of both.

Richard Hortonrichard.horton@lancet.com